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APPLICATION FOR PERMIT !� SAN JOAQUIN'LOCAL HEALTH DISTRICT I' 4 I! 1601 E. HAZEL T ON AVE., STOCKTON, CA I' -Telephone (209) 466-6781- PERMIT EXPIRES"'I YEAR`FROM DATE ISSUED (Complete in Triplidate) 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. i , Job Address 9,01? S� �E� t I, City rA D/ _ Lot Size z a PM Owner's Name 1�C y0 Q/ Y. �2��_E/%//V S7 /fATj Address 7 ,i WPhone -6'7 d Contractor l tVA14 gr 7" Address da ! L II TYPE OF WELL/PUMP: License No. Phone II NEtiN'WELL�--1 '-�'-- 'WEL'LAEPLACEMEN7;❑ h PUMP INSTALLATION , DESTRUCTION ❑ _...__�_, LLA_TION ❑ SYSTEM_ REPAIR O DISTANCE TO NEAREST: SEPTIC TANK v = OTHER,pI jl7� �� SEWER LINES � DISPOSAL FLD. ��. FOUNDATION AGRICULTURE WELL PROP• LINE OTHER WELL PITS/SUMPS--. " INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial f ❑ Open Bottom ❑ Manteca , I Dia. of Well Excavation Dia. Of Well Casing 1 }`Domestic/Private $Gravel Pack r ❑ Tracy Type of Casio 3 ❑ Public r ❑ Ot er g�-�-�� Specifications I� O I ❑ Delta Depth of Grout Seal F' Z.S� _ rn n Type of Grout ov / / QApprox. Depth ❑ Eastern Surface Seal Installed by I� Repair or ne ❑�Type�of Pump H.P. State Wo Done I� O Well Destruction ❑ Well Diameter Sealing Material (top 50') � Depth Filler Material (Below 50') n TYPE OF SEPTIC WORK:, NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {NO septic system permitted if public sewer is J Installation will serve' Residence available within 200 feet.) �� Commercial� Other Number of living units: Number of bedrooms Character of soil to a depth of.3 feet: I� SEPTIC TANKater table depth I I O Type/Mfg e/Mfg W � 'PKG. TREATMENT PLT, p Capacity. No Compartments IM li �` Meihod of Disposal IM # Distance to nearest: Well ^^� ^= oundatibn' F LEACHING LINE Q No:& Length of lines - Y ' FILTER BED Totallengt_h/size Di -' IM ❑ stance to nearest: Well Foundatio�ny} t Property Line t �� F ■s SEEPAGE PiTS M Depth —Size Number y I l SUMPS O Distance to nearest: Well DISPOSAL PONDS Q Foundation �"Property Gne � 1 hereby certify that i have"prepared this application and that the ti—rk-{will lie dbr e'irfiacc6-rdance.with`San.4oaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the followin +�J "rtvt employ any person in such manner as to become subject to wo kman's compensation mpensation la s of Califoperformance n ah�Contractor'swork for which opsub-contracting Is�hall not � certifies the following: "!certify that in the performance of the work for vvhFch this errtlit is issued,f shall em Iv signature t tion las of Carrnia. p p y persons subject to workman's compensa- The applican ust lfrfor all re u' ms q ons. omplete drawing o reverse side. Signed A yv ! Title: i �l. Date: F U RT USE ONLY 'Application Accepted ,. Date a Pit or Grout Ins _ y ate Final Inspection b .a. e .� Date Additional Commen ! :f. j k ❑ Stk 466-6781 ❑ Lodi 369-3621 T " ❑ Mant§ca 7104 menta ❑TracyApplicant- Return ll 835-6385 Y T Health rmit/Servi15/01 E. Haz i'toq Av .,t P.O. Box 2009;.S ,, 952Q1 11 FEE AMOUNT DUE AMOUNT REMITTED � INFO CASH RECEIVED BY DATE I :I PERMIT'IVO r + EH 1324{REV.t/B 57 EH 1428 l 3, ;00 Osco