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APPLICATION FOR PERMIT • T AN JOAQUIN LOCAL HEALTH DISTRICT pAYMN 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 `BAR p 2 1990 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 10AOU N CO�VCSS (Complete in Triplicate) F',8UC NEA1 W6A iH p1V1�i4N c tAUt, d.This application is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the aas�iM��4� b made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the ules and Regulations of the San Joaquin Local Health District. //J -nnt - RQ Eb 16'I City Lathrm) ' Lot Size "300 SLG PM Job Address _- ,.... I Owner's Name Lyon Co;(IIIIUnitieS Address 2707 L'' 2rPT00nt ( StOc`lci:nnl Phone 209-467-156J P.O. Box. 1.08 (96021) Contractor`' th. 9?J.1.ey Dri-l.l_deyj, TnC COrnin , Ca .License No. hl£3f'3t} Phone — — �7_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ m�///� 6 PUMP INSTALLATION ❑ SYSTEM REPAIR 13 OTHER 0 T$Onitorlllj_�,' 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 SPECIFICATIONS E] Industrial ❑ Open BottomINManteca Dia. of Well Excavation1 0 t1 Dia. of Well Casing tl ❑ Domestic/Private :1 Gravel Pack ❑ Tracy Type of Casing 4Ch d0 PV0 Specifications PI Public F1 Other ❑ Delta Depth of Grout Seal V,,1ri 01J S - Type of Grout_j eat eF t I I Irrigation V s—rApprox. Depth I I Eastern Surface Seal Installed by OPmr'nl - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') 11011i torinc Depth Filler Material (Below 50'1 — TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION 1 I DESTRUCTION I I (Nosbleic syste n m fitted if public sewer is avaInstallation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth i 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 t� DISPOSAL PONDS ❑ 1\ I hereby certify that 1 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 D31rict. 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 California." The applic t must call for all re i inspections. Complete drawing on r e side. _ Signed X Title: Date: FOR D TMENT S Y (\� Application Accepted by Date J — �o Are Pit or Grout Inspection by r Date `7 al Inspection Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 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 CK RECEIVED BY DATEPERMIT*NO. INFO �(7-� Sr Q . EH 13-24(REV.1/x5) 5 . (/v J " " 38J� —J /U / O—Li 60 EH Was