FIELD DOCUMENTS AND WORK PLANS 1988

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APPLICATION FOR PERMIT f� ��a > N JOAQUIN LOCAL HEALTH DISTRO PAYMENT — SANJOAQUIN LOCA ItEALTH DISTRIq901 E. HAZELTON AVE., STOCKTON, CA RECEIVED __EWIRONMENTAL HEALTH DIVISION Telephone (209) 466-6781 _S.CJ. LU FERM1T PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SEP 1.2 1988 (Complete in Triplicate) fINVIRONMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal the . This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the a t e San Joaquin Local Health District. Z D Job Address q lM�-,�'`�' w�sl, At C/r.,,,l .fr /1/ City-�1� YCxD/y Lot Size P Owner's NamLeDl`L�l �L��//O Address /-M� 1✓- f/�i�l�(f �S/GCee;&,,,7, Phone d Contractor �t(/i4-G Are re �/17L1�f�;l y�i <-/Y' License No.SV1 7 Phone�f l!a<'•7 TYPE OF WELL/PUMP: NEW'1/4/Address 89: WELL REPLACEMENT ❑ DESTRUCTION Ll PUMP INSTALLATION >t SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 2_J_ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n ('✓V Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �J ❑ Domestic/Private [&-Gravel Pack r ❑ Tracy Type of Casing /E e-- Specifications (-1 Public N Otheftf/41172 " (-1 Delta Depth of Grout Seal _Qr !/ Type of Grout futc& _ I I Irrigation _Approx. Depth I I EasternSurface Soul Installed by Repair Work Done U Type of Pump �/V�m H.P. Z'2� State Work Done 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 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. [_1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED Ll 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 I 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 Californi .' The applicant mu call fo aaH'Y' Inspections. Complete drawing on verse title. 1-- Signed X '7 / Title: / f-t��N f/.� - Date: r FOR DEPARTMENT USE ONLY p p� Application Accepted by Date 9—��-0 O Area Pit or Grout Inspection by(( /�/J/-�/ �,y,Dale /J,,Fiinalll Inspection by o�J Date Additional Comments: JIP ' ,I(.�/ `� 17`- �/NL-/��/97t� LGJ�L. ��//fyLC/r�� Oa Y.f7 O Stir 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 INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. ♦ EH 13.24(REV.r/n51 EH 14 28