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u - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT p 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 �C� f el-1A0V PERMIT EXPIRES 1'YEAR FROM DATE ISSUED G4J 1 L,� G (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 Job Address [— City Lot Size PM Jr Owner's Name f� L\��f� � Address [ � �+2-Phone -7 -5 71 Contractor 1A'/�� /YS $r7ir+ddress [_ / fffGOXAI09L.icense No. I Phone - TYPE OF WELL/PUMP: NEW,WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION)VRJW.444F SYSTEM REPAIR ❑ -AN OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE,WELL OTHER/WE 1L PITS/SUMPS 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 Type of Casing Specifications Public F Other I ❑ Delta Depth of Grout Seal Type of I I Irrigation —.Approx. Depth�I Irn Surface,Seal installed by /• �/ _ Repair Work Done ❑ Type of Pump H.P. I�/ State Work Done Well Destruction ❑ Well Diameter f Sealing Material (top 501 1 76-W yrs/ 6 Deptht Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l.] REPAIR7ADDITION I I DESTRUCTION I 1 (No septic system permiite if public sewer Tst 40 available within 200 feet.) W 1-r#.) AV,IN1.11 installation will serve: Residence_ Commercial_ Other a � T Number of living units: - Number of bedrooms Character of soil to a depth of 3 feet: Watei table,'depth SEPTIC TANK ❑ Type/Mfg Capacity No/Compartments PKG. TREATMENT PLT. ❑ Method,of Disposal --r- Distance .0Distance to nearest: Well Foundation Propertty Linn/ LEACHING LINE ❑ No. & Length of lines E Total length/size/ FILTER BED ❑ Distance to nearest: WA.11 Foundation Property/Line r SEEPAGE PITS 11 Depth a Si e � � fJumber'�' , SUMPS D Distance to nearest: Weil Foundation Property Line DISPOSAL PONDS ❑ j hereby certify that I have prepared this application and fiat the work will be done in accol(da"ne with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Dis#(ict. I -", 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 work manr's compensation laws of California." Contractor's hiring or sub contracting signaiuU's certifies tlpe following: "I certify that in the performance of the work fdrrhi'elthis permit is issued, I shall employ persons subject to workman's compensa- � tion laws of California." The applicant r t require ns. Complete dtawi�lg on rev se /id, . /J/ fi ( I" Signed X� TieV` Date: 0 F4VDEPAFiTMEN USE�ONLY f Application Accepted bye A b Date - Area �� r -- • y �'=�---Rate-- ^- Firial Inspection by Date � i .�1q/F-1- s 7`�..f n Gi¢r �+-CG.. tict./ F"�t.uj' {.(4d i.. c f Cid( aa'••ti•- . Additional Comments: r�>till Aa. F Q. � fdp� .h J9wf._aF�S • m z.�ll �U,.. Orf w/�� f ❑ Stk 466-6781 E] L idi3 -3621 ❑ Manteca 823-7104 El Tracy 251385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PEERMIT'NO. ♦.EH 13-24 MEV.1/R 5) EH 14-28