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/ APPLICATION FOR PERMIT ! SAN JOAQUIN LOCAL HEALTH DISTRICT p4yMENT 1601 E. HAZELTON AVE., STOCKTON, CA R E C E I V E D �j Telephone (209) 466$781 µG` a�ERIt�IT EXPIRES 1 YEAR FROM DATE ISSUED NOV 131987 Leman— � v��"�✓k (Complete in Triplicate) `.�1 L H ALTH Applicat ion he, San Joagtdn Local Health District to•permit to construct and/or install the work yews.��tcation is made M kl County Ordinance No.6t9 for aswegs or No. 1862 for web/pump and IM Rules and R osquin Local Health District. Pa.+rolwrK SforoL ntmirlaSL 1 Gd•t4)a4hi#19fon Sf. $ Navy Driv- Job Address Pyr+ C}or'Y- on City stceLfo/1 La Sim dyoorx X600 PM Owners Name Pnr+ O� S-'drJ(fan Address 0,001 Ill. 11)aAh;gt11 St.4/Y-2370 Pharr Contractor Address I cf/ ) License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION 11 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �� a DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE Ido FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r/ Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 10 Dia.of Way Casing ❑ DomestWPrivate ❑ Gravel Pack ❑ Tracy Type of Casing $Cti.40 PSpe ifiaations VG ❑ Public Other ❑ Delta Depth of Grout Sesl -1 4n !3' Type of Grout ❑ Irrigation --Approx. Depth O Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump finny H.P.—.I State Work Done Well Destruction ❑ Well Diameter carr Sealing Mdterial Itop 5(') r Depth r Filler Materiel (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION O (No septic system permitted if public sewer M available within 200 feet.) Installation will serve: Residence_ Commercial_ Other y Number of living units:_ Number of bedrooms t Character of soil to a depth of 3 lest: Water table dept SEPTIC TANK Cl Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. B Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Lints SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 workmen's compensation laws of California."Contractors hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shell employ persons subject to workman's compenx- tion laws of Calf The The applicant m all for all (a ocf� Complete drawing on rever 4 da. rJ^7 Signed !- Title: � fd/7iS. Date: //1�- rT FO A �U Y // C/y Application Accepted by Dale ti/�/LD '" o 77—Area Pit or Grout Inspacti b Date Final Inspection by Date Additional Comments: ❑ Stk I66-6781 ❑ Lodi 369-3621 ❑ Mentece423-7104 ❑ JAcy 83,rr g38$ Applicant • Return all copies to: Environmental Health Permit/Services 1901 E. Hazelton Ave., P.O. Box 2 , CA 96201 v INFO FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. y[H I1N UIEV.n r s sl J ,I EH laza 7 Q- —�il�j