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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE�TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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. L �i . Job Address I P L ►l r_ 4 City2EY'Clt/V 4%. Lot Size 40'0 4c' PM f` // __ rr �— W Owner's NameS44 f N �.O '`Address Phone li�37 Contractor's Name 10/50 h /3 ckti Ops._. License No. L/_3 Phone q7— TYPE OF WELL/PUMP:'ems`'. NEW'WELL ❑ 'WELL REPLACEMENT ❑ DESTRUCTION_LJh l PUMP INSTALLATION 0-' ') #'° SYSTEM REPAIR ❑ OTHER ❑ J DISTANCE TO NEAREST: SEPTIC TANK ER LINES DISPOSAL FL!;� ITS P P. LINE FOUNDATION AGRICULTURE WELL OTHER WELL /SUMPS INTENDED USE TYPE OF W L PR LEM AREA CONSTRUCTION SPECIFICATIO S °� F1 Industrial VGravel' m Manteca Dia. of Well Excava;ion- -- - pia, of Well Casing }� ; ❑ Domestic/Private Tracy Type of Casing I Spec cations ❑ Public - ❑ Delta Depth of Grout Seal` Type of Grout ❑ Irrigation Depth ❑ Eastern Surface Seal Installed byRepair Work Done ❑ Tt `t H.P. } State Work Done Well Destruction ❑ Well Diameter �r Sealing Material (top 501 j I Depth IZFiller Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION" REPAIR/ADDITIO DESTRUCJION ❑ (No septic system permitted if publi sewer is ad'aila`iil )"t eOQ a ►� �� Installation will serve: Re/sidence Commercial_�"�Other 7— 411 /N Number of living units:L Number of bedrooms ~ Character of sail to a depth of 3 feet: C a °"{ .Water table depth S � r t ._. SEPTIC TANKC/454+yuK Type/Mfg. _ Capacity l,20 Not. Co..mlpartments ° PKG. TREATMENT PLT. ❑ , �o. Method of Disposal,,_ sDistance to nearest: H41ell,` `�Q Foundation _ Property Line / y T LEACHING LINE No. & Length of lines M`- a ,'` -CT,;-A(-Cyt length/size FILTER BED ❑ Distance to nearest: Well ZQ& Foundation 7.0-._f`?� Property Line SEEPAGE PITS ❑ Depth Size Number. is � .3 n a SUMPS rh; Distance to nearest: Well�1��-Foundation Property.Line d ''' cl DISPOSAL PONDS ❑ f �tY{ "� ! ` I hereby certify that I have prepared this application and that the work will be done in aceordan a with San Joaquin coOnty ordinances, state laws, and 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 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."Coritracto>'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 shajl.emkloyipersons subject-to.workman's compensa- tion laws of Califor a." The applicant m c or all required-ins ctions. Complete drawing on reverse side. Signed XTitle: FDateY �`/o �� I s FOR DEPARTMENT SSE ONLY i ( �� Application Accepted by �✓-=t '�' ,.• i Date .� 7M f-i ,Are �1 t ,/ Pit or Grout Inspection by v Date Final Inspection by Date Date al Additional Comments: 'L 4 S 0 (� ' Stk--46�6781 °Y O L di—3�=3631 ❑-flAantep-&23-7104-----G-Tracy 836-6395 TOvIe- vmor, Applicant- Return all.copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.-,-P.O. Box 5 IStk.,-CA 95Return FEE INFO AMOUNT DUE AMOUNT REMITITED SH �. RE_Et�IVED BY DATE P/ERMIT"N0. +EH 13-24(REV.10/83) �11-OV C AW V-!✓—M g/•,�1 9 EH 1428 r� YY�� Y/ /