FIELD DOCUMENTS AND WORK PLANS 1988

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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT C (,� 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED IAN JOAQUIN LOCAL HEALTH DfSTRI�7 Telephone (209) 466-6781 ENVIRONMENTAL HEALTH DIVI� TT EXPIRES 1 YEAR FROM DATE ISSUED SE11i�1� D SPECIAL PEI&1�IIT (Complete in Triplicate) M ENVIRONMENTA E TH . Application is hetehy made to the San Joaquin Local Health District for a permit to construct and/or install the wop iT� gFflis appllcaoon Is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1062 for well/pump and the Rules and PR'' 1 bbff��the San Joaquin Local Health Distrito. 7 Job Address �' J S-7— :F27 '7+n�ry. ,j / �}-� /��City i7i✓ir Pzz„ Lo[ Size /'/! r^pN1 Owner's Name ` �f l!/U_(,(hu� ? p Address !.J V/f., flAI-If 4^"f—-f4 CLri3e Phone !Z J `J I.rl Contractor/L7 kAG //f Address !��G�0�� License No. Phone��.� O TYPE OF WELL/PUMP: NEW WELL e.kT WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONAw-- SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ZUr- DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS _ /INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private P Gravel Pack ❑ Tracy Type of Casing Sr / Specifications / 1-) Public .fl Othe9Vtdtr`V1?'rfl Delta Depth of Grout Seal Z/y�0 Type of Grout I I Irrigation ___ Approx. Depth I I Eastern Surface Seal Installed by /L&M±L - Repair Work Done L] Type of Pump f v80" H.P. . l/—Z State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 A Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) 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. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well_ Foundation Property Line LEACHING LINE ❑ No. & Length of lines _ Total length/size FILTER BED ❑ Distance to nearest: Well _ Foundation Property Line SEEPAGE PITS I I Depth Size__ _ Number SUMPS IJ Distance to nearest: Well 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. 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 manner as 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 performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant muussj,caJ%Vj6rJ all re uire omp late drawing on rreee rse`gide. ) p p Signed X a//Y////-�'l Title: r/ 0 /.�V/,- Date: / FOR DEPARTMENT USE ONLY Application Accepted by _ Q/L( / Dale 1 T?�_ Area Pit or Grout Inspection by �yN Date _ Final Inspection by Date Additional Comments: �u- ✓I G/ 4 �_rr L �/tr ( �J�/I.��y /�� B� Av ve O Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BV INFO g DATE PERMIT'NO. ♦.EH Ia-26IREV.vx51 i ,moi L /�— �!�/ - EH 14]6