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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CAPAYMENT Telephone (209) 466-6781 RECEIVED PERMIT EXPIRES 1 YEAR FROP DATEPSAff 7 1990 (Complete in Trip' ) Q g JOA, IN (.01UNTY Application is he+eby made to the San Joaquin Local Health District for a permit to const c o I�_ r h5 d S ,nirttl1�'+s application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/lid(} ( �j ��idr r5i'the San Joaquin Local Health District. Cj� —r /� Job Address r + nton JI a City l an-tcCO- Lot Size '45CZCr-t_S PM Owner's Name C1 of' ��C--• Address f WVS ocil_�_2_LLu�! Phone�g T� Contractor 5ee_+r _r-n Address 2825 E•Pyr4le J16 S LiiseCNo.o.C5�S/2263Phone M-13,41� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER SC'Ii- B('A/MQS DISTANCE TO NEAREST: SEPTIC TANK >50 SEWER LINES 756 DISPOSAL FLD7 50 PROP. LINE }SO FOUNDATION _ AGRICULTURE WELL 7?�_50 OTHER WELL? 50 PITS/SUMPS>__SQ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION I l Industrial I-] OpenBottom [I Manteca Dia. of Well Excavation Dia. of Well Casing /A [] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing NTA ' Specifications Ce^Crifl. ['I Public (-I Other I 1 Delta Depth of Grout Seal *?D-415 Type of Grout IAajvnl k, I I Irrigation _.--._ Approx. Depth I I Eastern Surface Seal Installed by SPCQ,4rvM Repair Work Done [I Type of Pump H.P. State Work Done Well Destruction C] Well Diameter Sealing Material (top 50') GernG�t — ►'f0 �D L( Depth 070—ZZs ** 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 11 Type/Mfg _ Capacity_ No. Compartments PKG. TREATMENT PLT. I-1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. & Length of lines ____ Total length/size _ FILTER BED L] Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number _ SUMPS LI 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, and rules and regulations of the San Joaquin Local Health Di§trict. 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 m st call for II quired inspections. mplete drawing on reverse side. r 1 W'' Signed f �LLr"L�l� lav Title: �7r�77 �f'y�Q x Date: �` v FFQ �T[Aff SE ONLY J Application Accepted by _ Date / Area Pit or Grout Inspection by Date _ Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CASH . EH 13 24(REV.v H 5) ��O w '�_'Z C,J v ��•r. CH 14 2e i