FIELD DOCUMENTS AND WORK PLANS 1988

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r\\��\ • APPLICATION FOR PERMIT • S r /�>�(` SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT SANJOA 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED QUIN LOCAL HEALTH DISTRICT Telephone (209) 466-6781 ENVIRONMENTAL HEALTH DIVISI9NMIT EXPIRES 1 YEAR FROM DATE ISSUED SEP 12 1988 SPECIAL PERMIT (Complete in Triplicate) 7l l Application is hereby made to the San Jo p ENVIR NME�NTAy�CI Joaquin Local Health District for permit to construct and/or install the work , aFlySch44Fi' t i anon is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rult San Joaquin Local Health District. Job Address City LyL.rAI Lot Size pM Owner's Name� � -6 Address 4ZO /V J//7f/LJi iC..-eF12'C T( J 7J�� j�� yJ /� ! !`av�P7hone Contractor 4-11/44. A�Wel Address LT License No. i�J 2phone3 O� TYPE OF WELL/PUMP: NEW WELL A[ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION WP SYSTEM REPAIR El OTHER ❑ cam-J � O DISTANCE TO NEAREST: SEPTIC TANK _. SEWER LINES - t _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ CV INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC TI NS Q irlndustrial ❑ Open Bottom ElManteca Dia. of Well Excavatiio�on.,,......�� Dia. of Well Casing 49`/s Domestic/Private ,.fTGravel Pack f1 Tracy Type of Casing�� Specifications [1 Public kr0therM1fA111'VYI l Delta Depth of Grout SeallUrvllfl Type of Grout_ _ 1 I Irrigation _,Approx. Depth I I Eastern Surface Seal Installed by /C--!✓,9-c_ 441 P/.4-el Repair Work Done ❑ Type of Pump : UCze 9 H.P._/- Z State Work Done_ Well Destruction El Well Diameter Sealing �al (top 501) 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 Ll Distance to nearest: Well _ Foundation Property Line DISPOSAL PONDS ❑ 1 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 Caliform .' The applicant mu call f air requi�liections. Complete drawing on re sid . _ ` ,, 7 }� Signed X Title: -1L? _ iz�lJ' Date: 4 /P- , Og FOR DEPARTMENT USE ONLY Application Accepted by ' I /� Date / / 6 Area Pit or Grout Inspection by ( / Date FiinalQ(nspection by Date 1. Additional Comments: Gv ilj1/1JLfC.f�(./rjzry A/.9'i! ��L�1(K ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 23-7104 El Tracy 835-6385 / ' U 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 RECEIVED By INFO CK DATE PERMIT'NO. . EH 1]34(REV_vxA �� EH ht3a Vim,/