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5� 14 APPLICATION .FOR PERMIT 1� ��. p SAN JOAQUIN LOCAL HEALTH DISTRICT 1 l � o 164i E. HAZELTON AVE.; STOCKTON, CA } 7 Telephone Qfts ,466-6781 JUN 5 1987 # PERMIT EXPIRES 1'YEAR FROM DATE ISSUED # h (Complete in TripljCate) €NVIROMENTAL -HEALTH FERMIT/SERVICE$ 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'tn compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welltpump and the Rules and Regulations of the San Joaquin Local!Health District. Job Address - Z,(0 zoo No,-P-4 k4 7d City Wfoll, Lot Size PM °f r 4.5333 Owners Name {h G�rr� Address �' m�t�e� tc,6 Phone a7i,-3 2e — szoo Contraclar + hL Address 1-a'tf✓�1 Sf License No. � Phone �5(6S�tNv TYPE OF WELL/PUMP; NEW WELL-O' WELL REPLACEMENT ❑ DESTRUCTION ❑ j PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. . PROP. UNE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDEO USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �tan�fi�; WdL, 3 ❑ Industrial C1 Open Bottom ❑ Manteca Dia, of.Well Excavation / Dia. of'Well Casing O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing sJA 4-0 IV L Specifications Q } 1'l Public FI Other n Delta Depth'of Grout Seal Type of Grout t I Irrigation Approx. Depth f I Eastern Surface Seat Installed by Repaii Work Done L7 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter_ Sealing Material (top 50') ' Depth Filler Material lBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIWADDITION 1.1 DESTRUCTION I I (No septic tem p system permitted 8 public sewer is available within 200'feet.) hist Lation wilt serve: Residence Commercial___ Other Number of giving units: Number of bedrooms E. Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityHo. f ompartnionts PKG. TREATMENT PLT,❑ Method of Disposal Distance to nearest: Well Foundation Property Line l LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation property Line . SEEPAGE PITS I I Depth Size Number l a. SUMPS 1.3 Distance to nearest: Welt' Foundation Property Line DISPOSAL PONDS fl 1 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. }come owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall :not employtany person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certitiei 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 musts cal for all required`I inspections. Compfete drawing on reverse side. �1 / Signed X + / (/� [!1C d+1 t 0 Y.'. , �s'l CX�'t Lrcy.��J ��l Z"7f O h�E1f �' Tri V c Titre: �� Date:. �ya FO EPARTMENT USE ONLY r Application Accepted by Date Area Pit or G�fout Inspection by Date IALFinal Inspection by Data { _ Additional Comments: .. CJ Stk °466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0-Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT OUE AMOUNT REMITTED f RECEIVED ey DA>E INFO H h PERMIT NO. . EH 1124(FtFv