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APPLICATION FOR PERMIT �` <br /> a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PAYMENT , <br /> p ,I,ie (209) 466-6781 ��Cr �V � <br /> COt1NI'Y-PLTBIT�� ES YEAR FROM DATE ISSUED <br /> 1NI0MMONMENTAL A C�arnplete in Triplicate) APR - 5 1989 <br /> t J I� SAN JOAQUIN COU <br /> NT Application plihetanyyyMy �i Jo j�yldt� alih District for a permit to construct and/or inst flu �Lcr��e i application is <br /> made in com list tt uut oun Ordinance No. 549 for sewage or No. 1862 for wall/pumlENVINc 4mtNTA�L 4tA Tan Joaquin <br /> Local Health District. ,/ p <br /> Job Address 44-3-3 _ _ n v� -K VN Lot Size 164 /i //O ' PM <br /> City <br /> Owner's Name Che.v✓o n USA Address <br /> Q d'�.ZSoo"- Sam t\ PhoneSwvr 4>1vsro r, R­1+1-r& ICA CA . 9t{5b3 <br /> 4z-aSZ� <br /> 7 <br /> Contractor Address a V�C22.U)�icense No.�Aa 9G Phone It y511' �2 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT El DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ J OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK —1/p SEWER LINESp Ito g9P(;AL FLD_A t/k PROP. LINE W 9/PQ r <br /> FOUNDATION AGRULTUKE WELL IVIA. OTHER WELL �_ PITS/SUMPS N j4 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> — i l 11 <br /> LlIndustrial ElOpen Bottom ElManteca Dia. of Well Excavation "' 1 1— Dia. of Well Casing `T <br /> Ll Domestic/Private Gravel Pack ✓T•c•c�X_�„ Type of Casing P%(r- Specifications Ce,,,e,+ <br /> ('I Public 1-1 Other ❑ Delta Depth of Grout Seal �^Z� Type of Grout`�Sr'ae" <br /> I I rrigation Approx. Depth I I Eastern Surface Seal Installed by -Dir Ile-✓ iyemtt•, d f <br /> y}1 1- V� <br /> Ke an�/oik�one� Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted H public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms (c` <br /> Character of soil to a depth of 3 feet: Water table depth 1 <br /> SEPTIC TANK ❑ Type/Mfg Capacity _ No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS 1_1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 <br /> rules and regulations of the San Joaquin Local Health District. <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> 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 <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X _ Title: C� Date: <br /> FOR DEPARTMENT USE ONLY t-� <br /> Application Accepted by Date ` 1 Area <br /> Pit or Grout Inspection by 7j✓t-F-�� Date Final Inspection byDate /U <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IEEE AMOUNT DUE AMOUNT REMITTED tt RECEIVED BY DATE PERMIT NO. <br /> EH <br /> . EH 1 �(REV,t/n5j <br /> tie 1-71— �/ I J ( J <br />