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" jrJa 5"1riAPPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA OCT 16 1990 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r!,.ONN!ENTAL.HMT (Complete in Triplicate) �r•AFHP'JI CES 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. 186 ell/pump and the Rules and Regulations of the San Joaquin Local Health District. y ,.1 Job Address _2700 lJ"G�i ��SfrtniL�7'LV�I City / t iz , J. PM /�,, /OS.S Owner's Name MCO A4460 C;rS (1i= Address Phone Ey.-1 824 Contractor Wtmr ul:a- M*r- Address Fi ', S' License No.j5 3€�Phone Lt - 7Z TYPE OF WELL/PUMP: NEW WEL6X WELL REPLACEMENT Cl DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINES 51 DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS q !/ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 10 2or� Dia. of Well Casing L4 Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ C L1 £�lL Specifications M Public n Other n Delta Depth of Grout Seal Type of Grout&&e Mt� I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump AJ H.P. —LVA State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 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: S �s C�"-'�Y Water table depth 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 _A)+ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size AJA _ Number SUMPS Ll 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 applicant must call for a required inspections. Complete drawing on reverse side. Signed �� Title: S'C Date: 1 C A 111 (1-0 FOR- A USE ONLY l Application Accepted by Date / / 2 Area Pit or Grout Inspection by Dater I� O Final Inspection by Date 2� �� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMIT-TED CCK RECEIVED BY DATE PERMIT*NO. ♦.EH 13.21(REV.t x 51 X I EH 11-2e // �- / �� r ? (J / / l l/ �.rlJ