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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT kJAYMEN , 1601 E. HAZELTON AVE., STOC'kTON, CA R E G E1 VE D Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JUN • $ 1990 (Complete in Triplicate) ��/ n^f�� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instill If�B�dAf1(M NTALsHFAL.-IT"s application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and th TJg ff"tp ns o t e San Joaquin Local Health District. /ice `��JJ Job Address Z7Cc� �tilc �'�} e� �iU[�T � City 5/07_K G� Lot Size"'Z� KTU'D PM Owner's Name tuc-el P,,t_nJrj_�, 6, Address /0S� LQ&'� �� Sj.. Phone 7/-3-`W-- A'L)( L, A _ CA,; Contractor 1-1141 Address , 'Fi .. . r_ License Phonee(� TYPE OF WELL/PUMP: NEW WELL Ed`IWELL REPLACEMENT ❑ DESTRUCTION Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK t,I.N SEWER LINES 1cX-3 DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,r ❑ Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation NU" Dia. of Well Casing CI Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing t'VL Specifications FI Public fa Other fl Delta Depth of Grout Seal Type of Grout�c I I Irrigation __.Approx. Depth � I I Eastern Surface Seal Installed by _ Repair Work Done Ll Type of Pump .�_ H.P. /'/i} State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 S Depth &4 -1&, Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial _ Other V Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: - S \� ti�'�rt��5 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines N Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size N N- _ Number SUMPS L_l Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 17 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 flealth DiMrict. 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 all required inspections. Complete drawing on reverse side. Signed X - Title: V 6Ze: . .-. I. Date: L (Ci l c 10 7,_M� SE ONLYApplication Accepted by Date / vAraa Pit or Grout Inspection by Date Final Inspection by Date-7 Additional Comments: No I_[)Q4�.5 ()AJ' g- [l�l— ok /c'LO)'Ii ilii w. ❑ 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 CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVE BY DATE PERMIT NO. FEE i r� ♦ EH 13-I'REV.I/n 5) 3 S , mG•—/7^ Q 7�/7 y EH 14.29 11