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`t► APPLICATION FOR PERMIT +� I SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT I 1601 E. HAZELTON AVE. , STOCKTON , CA RECEIVED Telephone (209 ) 466-6781 � Ip I r 1989 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED_ SAN JOA OUIN COUNTY ( Complete in Triplicate) ��+IP'IU6LICKrHI rEpAL{T.�H� ISTELR1VIIC�/EeSI(�� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instalFf11d 11324711WAtRh' L�4t'rllitrA.' TflJs' (,t(7W9 tion is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 11162 for wall/pump and thu Rules and flegulations of ilio San Joaquin Local Health Disuictt.. 'a{r�^' l ,,y/_ ^ Job Address ,vaSl ©✓L\ �f City 5��'K�,'r -� -�•l.at Size�1►a- E,f, PM Owner's Name � c Address �/�z o� r r "'x�"" `�� Phone • _ 71 _ Contracto . �1119 Adiress (000_-l.q_ S _ License No, 05 �SP one�� _ TYPE OF WELL/ PUMP: NEW ELL WELL REPLACEMENT I I DESTHUCHON I I PUMP INSTALLATION ❑ - - SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL __ OTHER WELL _ PITS/ SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION _SPECIFICATIONS MZ Et Cl Industrial CI Open Bolcom CI MantecaDia. of Well Excavation . �. _— Dia. of Well Casing —�-3� I Domestic/ Private 6106ravel Pack I.1 Tracy Type of CasingS � _ {1'_jt Specifications ,,,,,.,�LL 1 ' 1 Public 1- 1011101 1 -1 Della Depth of Grout Seat ,_ Type of GrouI"EV+_UMUAM 9rian1 Approx , Depth I I Eastern Sulfaeu Seal Installed by mk_6on' e - 1I Type of Pump -- H , P. State Work Done Well Destruction LI Well Diameter Sealing Material ( lop 501 Depth Filler Material ( Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR /ADDITION I I DESI IUICTION I 1 ( Nu suplic system prumnwd it public sower is I v available within 200 foul . ) O Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ____ Water table depth --_ SEPTIC TANK ❑ Type/Mfg _ Capacity —_-_ No. Compartmants PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well _ Foundation Property Line LEACHING LINE Ll No. & Length of lines _ Total FILTER BED LI Distance to nearest: Well _ Foundation __ Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well foundation ._. .____ Property Line DISPOSAL PONDS 1 -1 - IT 1 hereby cenify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stain Paws, and rules and regulations of the San Joaquin Local Health Di3trict. Home owner or licensed agent's signature certifies the following: 041 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California. " Contractols hiring or sub-contracting signature canities the following: "I cenily that in the performance of the work for which this permit Is issued, I shall employ persons subject to workman's cornponsa- tion laws of California." The applican muss care ll for all squired inspections. Complete drawing on verse �Sttde seJ / O /G & L`DLOG /S % Signed X f ,� Title: j,YO /a.[ _-_ Date: ,_I_ r Ear' _Lt/ FORD ME ONLY 9 � _ t Application Accepted by Date re Pit or Grout Inspection b Data Final Inspection by / Date Additional Comments: O Stir 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 875-6385 - Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED �ASII RECEIIV�E/D By DATE PERMI7' NO; r ♦ EN 13.24 (REV. Ilx9I � � 3S 1 �r 71 o / EN 14-M ✓✓ " t/ , /