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APPLICATION FOR PERMIT 'PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 NOV 17 1988 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicatel ENVIRONMENTAL HEALTH PERMIT/SERVICES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described_This 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. ,,/ Q Job Address a 7 17/eV:)_ "/�" � � � e`, City A 0 t�N�f Size U A C PM Owner's Name A C_. �_�`��a� `� �1Cddres�sy S �� Phone/ / Y—Z 3 �o Contraam� to cS Address j�0_a__,5 4C 1` k.QN 4ense NoP,.37- 4- _-'-Phone_7yS_/3 Sf TYPE OF WELL/PUMP: NEW WELL 71 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 17 SYSTEM REPAIR 2�-' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 7S-10 IS SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing "orneslic/Private ❑ Gravel Pack E3 Tracy Type of Casing _ Specifications 1'1 Public n Other 1.1 Delta Depth of Grout Seal __..._......_.- Type of Grout I I Irrigation Approx. Depth I ! Eastern Surface Seal Installed by Repair Work Done L� Type of Pump H.P. _ State Work Done T Well Destruction C Well Diameter 'I `-s-.51�Q /�.._.� *+ �4�.-3v J Depth -- F. .) —-- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t I DESTRUCTION I I INu septic system permitted if puhlic sewer is available within 200 feet.1 Installation will serve: Residence_ Commercial Otltur Number of living units: Number of bedrooms. Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK LJ Type/Mfg Capacity _ No. Compartments _ PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well . Foundation Property Line -_ LEACHING LINE 1-1 No. & Length of lines _ Total length/size ___.__ FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size __ Number SUMPS Il Distance to nearest. Well Foundation Property Line I DISPOSAL PONOS U - 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."Contractoes 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 must call for al requireddiinsspeccttioons. Complete drawing on reverse sidu. Signed X -/��"C a a+-�r� Title. <ZN- _ _.. _ Date: FOR DEPARTMENT USE ONLY Application Accepted by ` _... _ Date ` "� f � Area r Pit or Grout Inspection by Date Final Inspection by_ 4421N Date[sC3t G� Additional Comments: ❑ Stk 466-6781 C Lodi 369-3621 C Manteca 823-7104 (l 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 ASH Cy RECEIVED BY I DATE PERMIT'NO. . EH1 '241REV.rinsr ,aj� EH 142E l./ IIJJ