FIELD DOCUMENTS AND WORK PLANS 1988

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g0 APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRI AN JOAQUIN LOCAL HEALTH DISTRICT ENVIRONMENTAL HEALTH DIVISIMI&I E. HAZELTON AVE., STOCKTON, CA SPECIAL PERMIT Telephone (209) 466-6781 M PERMIT EXPIRES 1 YEAR FROM DATE ISSU ©� „ (Complete in Triplicate) Lj Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. TMs application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.L / Job Address 376 �� J/ iiG/j f9 Cit(y��CArC Axl Lot Size �JpM ({ Owner's Name, / y w7- Address /� I�I/ J//fi�'�/f-/ �Tprrz(c/yry Phone ` 6- l 7 Contractor fid!/ e—ef q ddress !J4-.(r_e-yi ritcd c-s9 License No.J"W337 Phone3 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 5e SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK Z f SEWER LINES Zz�_ DISPOSAL FLO. PROP. LINE ._ FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IR Industrial 60 pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ci ❑ Domestic/Private yGravel Pack ❑ Tracy Type of Casing -f 7-er-e- Specifications I'I Public 1Fd Othed'+7oq t; n Delta Depth of Grout Seal pp Type of Grout I I Irrigation 1_zI_JApprox/ epth I I EastornSurface Seal Installed by Y! Repair Work Done ❑ Type of Pump f I-iO H.P. �;2. State Work Done_ ^ Well Destruction ❑ Well Diameter Sealing Material (top 501 r, Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I (No septic system permitted if public sewer is �l v Installation will serve: Residence_ Commercial__ Other available within 200 feet.) S 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 ❑ 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 Oillrict. Home owner at 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 m 3t or all req i till . Complete drawing on reverse Ida. Signed X �i ^ Title: �/' / _ Date: I FOR DEPARTMENT USE ONLY n in Application Accepted by � d - -- Date 2 Area Pit or Grout Inspection by /f y Date Final Inspection by Date Additional Comments: e_ _7 �/[/ G.i (A/y2`y'/,��pj.WSC /lrtce/ Be ©� ❑ Stk 4 ,(Zl - ✓Jj��/r466-6781 ❑ Lodi 369 3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Alt. / 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 C FE11VED11YFO ASDATE PERMIT NO, ♦ EH t3-2x IREV.1/x51 % J .S EH 11-29 3 �' ��