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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �-- 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 1 ! PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDJ,�, (Complete in Triplicate) -n n D :j e990 l_ 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. 1 Job Address -�' 7 5— ,_1 e'l City /9'A,0\! Lot Size PM I Owner's Name /�1— ';/�lf','ir`'q�`� Address p� r�e' 1� �,� ` ice 'ai = r/7�F� Phone r11 /L!�( ' 4 P.O. Box 567 Contractor BE= DRILLS INC. Address ConBneree Citsx CO 8003license No. 263675 Phone(303) 286-77 6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑J7/yq�n/rfzrt ;✓;'t/�f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Q DISTANCE TO NEAREST: SEPTIC TANK Ao_"'X�e SEWER LINES _ DISPOSAL FLO, '_&" PROP. LINE rf� FOUNDATION AGRICULTURE WELL 1/'?s1 OTHER WELL ` D� PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation `��r Dia. of Well Casing 41 _1 Domestic/Private ❑ Graver Pack G Tracy Type of Casing ^"'— Specifications Public l`AOther F-1 Delta Depth of Grout Seal ` ) ! Type of Grout Irrigation Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done Ll Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter a Sealing Material (top 50') Depth_ !s7-<% Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence __ Commercial __. Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK F_J Type/Mfg - Capacity No. Compartments Disposal Dis of Method PKG. TREATMENT PLT. . P Distance to nearest: Well Foundation Property Line LEACHING LINE L- No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS 1 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, ands" 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 wnich 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 womman's compensa- tion laws of California. The applicant must call for all requiod;hspections. Complete drawing on reverse side. Signed R = <_-�-. ' Title: Vice President Dace: January 30, 1990 iiEP ctti"T USE 07+iLY Application Accepted by .__'��%'�,7 Date /. _ A��s: � Pit or Grout Inspection byVMa -" Hnai inspection oy Additicnal Comments: --- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-711;4 Ei Tracy 835-6:18'> Applicant - Return all copies to: Environmental Heald-. Permit/Services 1601 E. Hazelton Ave. x - 95201 FEE AMOUNT DUE AMOUNT REMITTEDr H RECEIVED BY u, TE 11 PERMIT NO. INFO FH 13-24 fREV, EH 14-28 "�