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} I APPLICATION FOR PERMIT i t� ..I. SARA JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZELTON AVE., STOCKTON, CA ' Telephoned(209) 466-6781 PERMIT EXPIRES 1'Y16AR FROM DATE ISSUED .` (Complete in Triplicate) 4 Application is-hereby made to the San--3o'aquin 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 2bas�CtS GQS cS7z7 bei j�, Job Address 90th S4cc CXerok e- 4oe- Lc�G ,2 Yo XZSbr City Lot Size PM /�� IN Owner's Named�74" Oil G4q?p�p y Address /tiv� &-//, e L QyG Phone O0�7).368r z7 3 �f Q�Gretaa�°t it 2"S ,I/tc, 7y111yilSh�5V.F, easu.• n,C 9 C511x" y64-71-7L Contractor 4 Address Ab-711 atxr k 1.541 Fief toA CA . 6 y�N Pholne&Wk_��Q1 License fVo TYPE OF WELL/PUMP: NEW WELL ❑ WELL'.{REPLACEMENT ❑ DESTRUCTION ❑ /naso' 7A_1 4&i. -5- PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER yr�z,d�rrfM �Yt�S DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Jam? DISPOSAL FLD. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well.Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T pe of Casing 'fit'40 G pecifications CerW j 6-i` F Public n Other n Delta Depth of Grout Seal --4D yp/e of Grolut S% , I I Irrigation a -Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. III _^State Work,Done i( Well Destruc��tfi�orl ❑ Well Diameter B r/ Sealing Material (top 5011 �e�7 &,Ak � '8 (Below t,*{►Yi /60frr1� Depth �— `"�v 10 Filler Materi I f Balow 50'I IM TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIR/ADDITION I I DESTRUCTION I I Mo siitic system permitrediif public sewer is ' f available within 200 feet.)'-, �' Installation will serve: Residence_ Commercial_ Other If 0 p Number of living units: Number of bedrooms y Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ElI1Type/Mfg ��! Capacity No, Compartments PKG. TREATMENT PLT. ❑ Method of Disposal II " Distance to nearest: Well foundation Property Line LEACHING LINE ❑ No. & Length of lines II Total length/size I� # FILTER BED ❑ `'Distance to nearest: Well I.Foundation Property Line SEEPAGE PITS I ] i Depth Size Number II k SUMPS ❑ 'Distance to nearest: Well Foundation Property Line DISPOSAL PONDS L] ai 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, an i rules and regulations of the San Joaquin Local Health District, III 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."Contractors hiring or sub-contracting signature certifies tA.ntu "I certify that in the performance of the work for which this permit is issued,I shall a lay persons subject to workman's compensa- tion laws " . _� I The applfor I req r inspections. Complete drawin onteveerrse side. Signed X Title: o o / Date: 1I Z 4S 7 4& J. FOR DEPARTMENT USE ONLY R le-t h�+ �� Application Accepted by L 1 t'Z�le fi I I Date Area .� t, Pit or Grout Inspection by Date E iY� Final Inspection by I� Date j Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823.7104 I� ❑ 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 DATEPERNlI7'ND. INFO CASH + EH 13-244REV.riw sr i5 II X5 .00 3 78 EH 14-26 ii 27'-4 k 6 F