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} APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-Ml 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. Job Address lJ O T �•�~ . City Lot Size PM LA 4wn�r s Name f IV. _ - �*� tlress ' V E � Pqh one �Vi Contractor D�,VLd tjtin S!*/ , Address rl tA/ Lar- License No. LZ_Phone TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT ❑ I DESTRUCTION ❑ A PUMP INSTALLATION ,❑ � t ' .SYSTEM REPAIR ❑ OTHER ❑ F DISTANCE TO NEAREST: SEPTIC TANK- SEWERILINES DISPOSAYFLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHERl,WJELL PITS/SUMPS UINTENDED USE TYPE OF WELL PROBLEM AREA —CONSTRUCTION SPECIFICAJ(ONS ^ ❑ Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation std P Dia. of Well Casing 1 E:1 Domestic/Private I❑ Gravel Pack C ❑ Tracy - Type of Casing Specifications ❑ Public ❑ Other F-1DeltaDepth of Grout Seal l Type of Grout EJIrrigation ---Approx. Depth LJEastern Surface Seal Installed by Repair Work O// Type of Pump'. H.P. m t$Work Done, ` W Well Destruction ❑ AW Diameter Sealing Material (top 50') k Q. Filler Material (Below 501 °'71 i TYPE OF SEPTIC WORK' STALLATI(iiN REPAIR/ADDITION ❑ DESTRUCTION {No,septic sj+stem permitted if public sewer is ayaifab�le/within feet.} Installation will server e�dence— �bee rcial_ Other ' 16 Number of living units: r Number of rooms = Character of soil to a depth off 3 feet: "i_."Water tale depth SEPTIC TANK Typ/ fg ►" �apcity ` - •NoCompartrrents z- PKG. TREATMENT PLT. ❑ Sli �"t y*-5 fCrMT t Method of DilFsposal _ � 1 S tS i,nCe o earest: eft� Foundation_601 Property Line f I ., � .. - �I LEACHING LINE NoN L ng of lines r �dtal engt size FILTER BED ❑ Distance to nearest: .r We Foundation / - PrDerty Line C1 I SEEMAGE"PhTS '; D thy'" -. -«�Siza - Numbs SUMPS ' Di to n rest: We• __._� Foundation I Property Line DISPOSAL PONDSQ'f y 1 hereby certify that I have prepared this application and that;t e work will be done,in acc rrdance with San Joaquin county ordinances, state laws,.and rules and regulations of the San Joaquin Local Health District 's J" � Home owner or licensed agent's signature certifies the followin : "1 certify that in,the perfo mance of the work for which this peimit is issued,Thall n6t' employ any person in such manner as to become subject to 4vo man's eompensa' on laws f California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance work for which this permit is i sued,I shall employ persons subject to workman's compensa- tion laws of California." .j The ap ca call for all required ' spections. Cc pl a rawing on reverse side. Signed Title: �' 'Date' FO 1 DEPARTMENT USE ONLY ` Application Accepted by Date Area V Pit or Grout Inspection by Da Fin Ins" c'on by Date -�� - - , Additional Comments: � ""' :, ❑ Stk 46&6781 ❑ Lodi, 369 362 Manteca 823 7104 ' Tracy 83x6385 Applicant- Return all copies to: Environmental Health Permit/Services 160VE. Hazelton Ave., P.O. Box 2009, Stk., ;CA 95201 C - INFO''--AMOUNT-DUE- ----AMOUNT aEMIITED,� � CK �, _.RECEIVEO.BX _DAFE M ,-_ _PERMIT_ND. + EH 13-24 1 REV.1/85: qr'� i `'�, F». ' 11 s� •—� EH W26 4J' �:?'-0- i ./