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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1:YEAR FROM DATE ISSUED (Complete in Triplicate) I Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I [ Job Address mile South V1ne • imile E . Harold City Escalori Lot Size PM Owner's Name L O Address 1-19352 S. Harold 95230 E,SCalpil Phone � � f Contractor P_u.rviare~Dri1z'ers�ddF �. P: p, BoX =64 Lndt�tkense-No.--3.7.7923_ .-Phone -88.7--3554 TYPE OF WELOPUMP: _ NEW WELL I!X WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ F° E SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES f DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA ',CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 12 Fr— Dia. of Wel! Casing 12 3/4 ❑ Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Casing steel Specifications t7 Public F1 Other ❑ Delta Depth of Grout Sear' C:;o. Type of Grout cement _ ZKI Irrigation 250_�pproJ Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. -State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth r� Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION Ll DESTRUCTION 1.1 (No septic stern i p y permitted if public Sewer is Installation will serve: Residence=� Commercial_ Other.. available within 200 feet.l Number of living units: Number of bedrooms Character of soil to a depth of 3 feet. I Water table depth SEPTIC TANK ❑ Type/Mfg ' Capacity No. Compartments PKG. TREATMENT PLT- ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of tines Total length/sizer FILTER BED F] Distartcerto nearest: `-r Well Foundation Property Line SEEPAGE PITS I 1 Depth --Si' + tt•� Number , - SUMPS Ll Distance to nearest: W ,.'s.},,,�"ell Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. a Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, i shall not employ any person.in such.mannaras to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the"performaiice of the work for which this permit is issued, I shall employ persons subject to workman's compensre tion laws of California." Th is ust c t for re�iredspections. Complete drawing on reverse side. Sig d X Title: _.Corp. Secretary Date: _4/26/88 FOR,IDEPARTMENT USE ONLY Application Accepted by Date f� Area Pit ortinspection by Dates Final Inspection by l � Date Additional Comments:. ! per. ❑ Stk Pa 466 6781 ❑ Lodi 369-3621 ❑ Manteca 823- ❑ Trac 835-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2099, Stk., CA 95201 FEE AMOUNT DUE INFO AMOUNT REMITTED CK 49 CASH RECEIVED�SY DATE PERMI7'N0. + EH 13-241REV.iinSY / ! —]D�� [L _, � �r/bibEH 1428 V ( 7 PL