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.i r APPLICATION FOR PER14T ` N JOAQUIN LOCAL HEALTH��DIS1AICT PAYMENT SA RECEIVED 1�1 �i ON AVE., STOCKTON,i CA ' 1G0?v'�jSHj�jy Telephone 12091 466-678 i DEC 0 1989 VlaI�AjAAI.' � n1 EXPIRES I YEAR FROM DA IS AN JOAQUIN COUNTY $A�jOA{7�Q�.1a�r�`t'014% Tpr3 [' i! �. (Complete in Triplicate)l �] BL MJF TI- r 11 8 T,i•'� i` ^+ ermit to construct andlor insta I Ili ork `i 0 r11li��Q� Application is �b (a to thefan Joaquin Local Health District for a p -it San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/ and the Rules and flegulations v made in comWlice w 3 Local Health District. f., PM `� r city of Size Job Address ( '32 */tom ✓ L Phone w'Address Owner's !Name 4480 70 Z Phone 6TZ 560 r ,� O 4c. ice No._ N L3 Ai resS DESTRUCTION ❑ Contractor WELL REPLACEMENT ❑ NEW WELL OTHER EI TYPE OF WELL/PUMP: SYSTEM REPAIR U PUMP INSTALLATION ❑ DISPIOSAL FLO. PROP. LINE SEWER LINES �— -- P1TSlSUMPS DISTANCE TO NEAREST: SEPTIC TANK --- AGRICULTURE WELL If OTHER WELL FOUNDATION }1CATlONS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIE pia of Wel! Casing — .—� ❑ Open Bottom ❑ Man—Manteca Dia. of Well Excavation I L7 industrial Type of Casing ✓L Specifications ,/ Gravel Pack ❑ Tracy k Type of GroutL� +•+ �^'a ll DomesticlPrivate n pelta Depth of Grout Seal I'1 Public 1.1 Other it Il Surface Seal Installed byI I I litigation -_—Approx. Depth l I Eastern I} State Work Done H.P. 1i Repair Work Done 1-3Type of Pump Well Destruction O Well Diameter Sealing Material flop 50'1 � - - ,�— CA��„�,'4v1r;,� Depth '6O r Filler Material IBelow 50'1 available within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIfllADDITION I I DESTflUCTION I i INo septic system pern��tted if public sewer is Installation will serve: Residence — Commer cial. Other — -- Number of bedrooms_—�-- Water table depth Number of living units: No; Compartments Character of soil to a depth of 3 feet: Capacity lam. — Method of Disposal ❑ Type/Mfg SEPTIC TANK I_; PKG. TREATMENT PLT.❑ IF Property Line —� Well Foundation�,-- Distance to nearest: II I! T�otallengthtsize ❑ No- &Length of linesproperty Line � ' LFA,CwNG LINE Well [-1 Foundation' — ' Distance to nearest: I w FILTER BED lI }Number Size �Y I` Property'Line 4 1 Depth Foundation�— SEEPAGE PITS Well I l state taws] SUMPS Distance to nearest: Joaquin c°unty ordinances, DISPOSAL PONDS ❑ application and that the work will be done'in accordance with San Joaq permit is issued. I shy Joaquin Local Health District. I Certify that in!fie perforlPmance of the work for which this p I hereby Carlify that I have prepared this app act to workman's com rules and regulations of the San ensatlon laws of California," Contractor's hiring or sub-contracting slg} Home owner or licensed ag ant's signature certifies the following'. " t shall amp ff rte loV any p °rmance the work for which this prmit is isksued, employ ers°n in such manna►as to become subject to workman's comp I, , employ persons subject 1 certify that in the pe certifies the following:" on re=ve tion laws °f California. Complete drawingI Date'. !leant mu t calf for uired ins ctio The app Title: 1 Signed X 5 DE EN71U5E 1VILY _ 0^ II{ U Area !i Data/ Date Application Accepted by pate 1— _ Final lnspectiori by Il i Pit or Grout Inspection by if ❑ Manteca 823-7104 O3 Tracy '$355 Stk., CA 95201 Add'itionel Comments* P.O. Box 2009. ❑ Stk 466-6781 C3 Lodi 369-3621 i I ii Applicant - Return all copies to: Environmental Health PermitlServices 1601 E. 'il HaxeltorihAve., DATE PER MI CASH I RECEIVED BY YNO! FEE AMOUNT DUE AMOUNT REMITTED INFO l J�O��QU i751�5 I + � , 1 . EH 13-24 IREV.1/AS) - - EH 14.28 _ - - - 17, I�