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i� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT j 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-67$1 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. 1i Job Addressp J�Q 0 4 ��i � V Q � lT1! " City �s('ftl (yj1 Lot Size 10AC/t j PM Owner's ,Name_ j !r r o{pRC:i ne3)-lor .Address_ -6 G©a f 6_(J.' IA- V -Phone- Contractor's Name i) License No. / 3 y 33 CI-.. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 7❑ ' .` DESTRUCTION, 0-' 1 V PUMP INSTALLATION-Oi' ,-4<SYSTEM REPAIR F1 OTHER C1DISTANCE TO NEAREST: SEPTIC TANK .w. SEWER LINES lj 4 ` c DISPOSAL FLp n PROPALIIVE A t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM'AREA iC6NSTRUCT10N SPECIFICATIONS' ❑ Industrial E) Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wel! Casing ❑ Domestic/ Private r ❑ Gravel Pack _ ❑ Tracy Type of Casing - '� \ Specifications , ❑ Public ❑ Other i� �i ❑Delta Depth of Grout Seal '` t ' Type of Grout �� ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H. P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') �. Depth Filler Material [ elow 501 4TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION A DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet) Installation will serve: Residence =�' Commercial Other Number of living units: --/— . Number of be rooms Character of soil to a depth of 3 feet: �d " Water table depth Iro I SEPTIC, TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑iN. Method of Disposal bistance to nearest: Well Foundation Property tine LEACHING LINE f '' > i ��. No. &'Length of lines ' 1 iN dotal length/size r FILTER BED ❑ Distance to nearest: Well r Foundation �_- Property Line 1 SEEPAGE PITS ❑ Depth Size Number i fis } SUMPS Distance to nearest: Well Foundation _.7� Property Line DISPOSAL PONDS TM❑ , 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, and rules and regulations of the San Joaquin 'L•ocal`Health District. Home owner or licensed agent'ssignature certifies the following: ',Lcertify-thatinahe 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 the following: " I,certify=that in the.perfo"-ance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California.,. The applicant mU all for all required -inspections. -Complete drawing. on reverse side. ^7 SigneTitleCI a Signed Date: RV r, F i FOR DEPARTMENT USE ONLY " Application Accepted r J7 _ �! by Date Area Pit or Grout ! spection by .'` ''� i� Date I ' .� Final Inspection by pate 2 - 7 Additional Comments:S _ 0 Stk 466.6781 �❑ Lodi 369-3621 f L7 Manta a' ffi3-7104 ❑ Tracy 835-6385 l Applicant---Return-all .copiesxo: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. -Box 2009, Stk., CA 95201 16 _INFO- AMOUNT DUE AMOUNT REMITTED CASH: RECEIVED Bl! + DATE PERIhAIl `NO. + EH 1324,[REV. 101 "`. �' EH 14_2fi � d -r` ,Ir- AF