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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA D <br /> Telephone (209) 466-6781 Q I o <br /> PERMIT EXPIRES TYEAR FROM DATE ISSU <br /> (Complete in Triplicate) SEP 2 7 1988 <br /> 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 <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and tEl'Ild' @HkliL {g"►41$tlitTNhe San Joaquin <br /> Local Health District. PERMIT 1 SERVICES <br /> Job Address "Trl I 147: . 7T�/Y ..y45am1 City Lot Size PM <br /> Owner's Name /_%// Address 4L9A:- 44W�.�Cr� � Zo Phone vO 7-5-3/ { <br /> .,.�t� <br /> Contractor Address,-2� G1 �!C CD ,.9.0 License No.46a,45 Phone <br /> TYPE OF W LL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 1 PUMP INSTALLATION Pf)Fj65Q/_AfEJ>SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: .SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNIDA TION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 30 Domestic/Private ❑ Grapel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public 71 Oth`o r �J 17 Delta Depth of Grout Seal Type of Grout _ <br /> I i Irrigation —Approx. Dopth I I Eastern ,Surface Seal Installed by _ <br /> r Repair Work Done ❑ Type f Pump 1 H.P. State Work Done <br /> Well Destruction 171 Well Diameter Sealing Material (top 50') <br /> Depth 1 .5�Riller Material (Below 501 _ A/�� <br /> TYPE OF SEPTIC WORK: NEW ! §.TA" IOW), ] IRCAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is N F <br /> available within 200 feet.) <br /> Installation1will serve: Reside c{ .£�_ Comr}1��cial other <br /> Number of{living units: Nrsr ,of Abe lm_s <br /> Character of soil to a depth of`3�fee �.^��--: Water table depth <br /> SEPTIC TANK . ❑ Ty"g��—�^ '- 0�' Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> y Di ante to nearest: Well_ Foundation Property Line <br /> � F <br /> LEACHING LINE S❑ No & Length of lines Total length/size <br /> FILTER BED1❑ DiE tance to nearest: Well Foundation Property Line <br /> 1 <br /> I <br /> SEEPAGE PMTS l I De 3th Size _ Number <br /> i <br /> SUMPS I Cl Ditance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS L7 <br /> hereby certify that NI ha'7e prepaad this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations4af4he San iloaquin Local Health District: <br /> Home owneri or licensed agent's signature certifies the following: '9 certify that in the performance of the work_•(�fo y��'�vvHt:h this permit is issued, I shall not f <br /> employ any person in such mann�r as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall emplo!P'&N subject to workman's compensa- <br /> tion laws of California." <br /> r : <br /> The applicant require tions. Complete drawing on rever faside, <br /> Signed,X i.�6 .�.-_ �� Title: ��� Date: A <br /> I <br /> FOR-DEPARTMENT USE ONLY <br /> Application accepted by Data Area <br /> 4 O <br /> Pit or Grout inspection by Dater­-' FinA1 I ection b Date o /� ` <br /> I y <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 3t3S3621` ]"fSnan"tet-"a��1371 racy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNiI DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMI7'NO. <br /> r.EH 13-24(R EV.1/9 51 I F'�... �y-7 <br /> EH 14-2B 9! �! � gg`�-S <br />