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I APPLICATION FOR PERMIT �I SAN JOAQUIN.LOCAL.HEALTH DISTRICT � 1601 E. HAZEL T ON AVE., STOCKTON, CA "Telephone {2091 466-67$1 y 4—Tl If% OL c PERMIT EXPIRES~1 YEAR FROM .DATE,.ISSUED..,; (Complete in-Triplicate) ;4.e 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. 1.862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. '0 ;�aaa cHE►e !1 D :` 1 = - Lot".Size -7sx i O PM Job Address 1 ~City 1d 11 ' Owner's Name Address L � N E Phone 11- Contractor��'► � Address ,Q, rd License No. '�3__Phoi',e NEW WELL ❑ WELL REP.LACEMENT-�❑ DESTRUCTION ❑ TYPE OF WELL/PUMP: ._,'*k � - __� ,-..�,�--PUMP-INSTAL-LATIONP`❑�- `" �SYSTEftA R PAIR ❑"SOT E p -,-• DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE {I I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS c ;' I INTENDED USE 'TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! " ❑ Open Bottom 11 Manteca Dia. of Well.Excavation Dia. of Well Casing ❑rindustirial p I r Specifications I r ❑'Domestic/Private ❑ Gravbl.Pack ❑ Tracy Type of Casing 0;Public ❑ Other ' " ❑ Delta Depth of Grout Seal Type of Grout pth (DEastern __ _Su face-SealAnstalled-by ntirrigation __Appirox. Del � Repair Work Done L� Type of Pump H.P. State Work Done 4 ' f Selling Material Ito 50'1 WI Destruction ❑ Well Diameter ,- 9 _ p _ y it se. � t �� Depth t Filler Material., TYPE OF SEPTIC WORK: ;NEW INSTALLATION ❑ REPAIR''IADDITION ■ PESTRUCTION ® (No eptic system permittedrif public sewer is -.»-� liable within 200 feet.) Installation will serve: Residence--!!!f Commercial, ,Other L��--- Number of living units: _j__-P Number of_bedrooms I. i I �' i• r Jz«_ ' Water table depth ° r Character of soil to a depth of:3-feet: t Q ---- i i J SEPTIC TANK B Type/Mfg PAria C + � Capacity 120[7 No. Compartments " . - ' € ' Method of Disposal I� PG. TREATMENT PLT. ❑ I a r P ,1 Distance fo nearest: Well - `�,. _ Foundation Pro erty Line r , aril Y LEACHING LINE 2t No. & Length of lines Total length/size I FILTER BED.. C] Distance to nearest: Well -•rte L ~Foundation/ Property tine IM _ i j SEEPAGE PITS f❑ " Depth ID �� Size D� O Number rt SUMPS !" Distance to nearest: .. Wel! PO� Foundation U3 Pyroperty'Lin -— 'T`"; DISPOSAL PONDS DI f - IN hereby certify that I haveyprepared 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 District.. r " C�:. �� " Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work;for which this permit isissued, I shall not , employ any person in such manner as to become subject to_workman'.s componsation.laws,of-California."Contractors hiring or sub-cont acting signature certifies the following: "I certify that in the,performance ofAhe work fortwhich 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 reverie side. w Signed X Title: /`��_4 Date: Q A?60 FOR DEPARTMENT USE ONLY p i y pate Area Application Accepted by �. t " Date 4 Final Inspection by I�. Date Pit or Grout Inspection by � � ... � ,I� ditional Comments: i3 t c tk 4.66-678,a .�„L] L . ..369=3621.®,,_,. 1:1-Manteca-AM-7104—❑�-Tracy -635-6385— App scant- Return all copies to: Environmental Health Permit IServices,1601,E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r w FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY PATE PiERM1T'NO. INFO � r .3-Iz- -17 s EH 13-24 4REV.1 i n s} -7-7v f� �� ' EH 14-26