FIELD DOCUMENTS AND WORK PLANS 1988

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• APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT SAN'JOAQUIN LOCAL HEAJArH(�ISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED ENVIRONMENTAL E�I it SION Telephone (209) 466-6781 SPECIAF,RI�tI PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SEP 12 1988 � (Complete in Triplicate) ENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install R.,rkOdR � s lication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and 6 an Joaquin Local Health District. 51,vec/f1/1 Job Address (LGlrtz N S 44r s7 �y�z/ ,A 'YY(G/ZO/7�/�� City��TJC{c,%/ry/ Lot Size PM Owner's Name' `� " J: "" Address /_.Y .✓!/YG��-!''L CC.PL^z'"C Phone _ Contractor/4e/lf%Jc (/4/?fJt-i!tyL'Y Address [:"11cz54- 'FiL`X License No.S?1337 Phant;y=T-rem TYPE OF WELL/PUMP: NEW WELL _ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION�e SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFI;;Q,fS / Industrial ❑ Open Bottom FJ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ?'Gravel Pack ❑ Tracy Type of Casing P41c- Specifications 1 FI Public rl Other�/f e,?ljly fl Delta Depth of Grout Seal42 Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done (.1 Type of Pump t UQ/Y1 H.P. %7 State Work Done— T. Well Destruction ❑ Well Diameter Sealing Material (top 50') ` Depth Filler Material (Below 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is \ available within 200 feet.) �• Installation will serve: Residence— Commercial __ Other 1/ 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 fa� PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well_ Foundation Property Line SEEPAGE PITS I I Depth ____Size _. Number SUMPS 1_7 Distance to nearest: Well _ Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. j 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 ofCalifornia." The applicant must II for reguked-mspections. Complete drawing on� r" '�S_y se si . r Signed X �--- Title: ��'� ' Date: � FOR/DEPARTMENT USE ONLY Q'�( Application Accepted by f/ Date Area V Area Pit or Grout Inspection by ///�J p,p-y_ Date /JF,iinnal Inspection by ppgg+ Date Additional y— Additional Comments: S� 117ze �/d1'fC-��fhtc(L/� / '-Cig /� S O 'j1^/til/N.H ❑ 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 N FO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT' O. x.EH 1331IREV.1/x51 +'C EH 1t-M —