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APPLICATION FOR PERMIT !� SAN JOAQUIN LOCAL HEALTH DISTRICT �S 1601 E. HAZEL T ON AVE.,..STOCKTON, CA II Telephone (209) 466-67811- PERM If 66-67811PERMIT EXPtfliS<9-=Y-EA-R FRRI 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 incompliance 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 -2 3 City' Lot Size `� PM - _ .. c _ _ Owner's Name _� Address �� !l a4'GV x1� _ Phone .._.-:�....,.....__....:-..._ _ is _` _ G z .Contracior. J l�� Address � � _ XOC� ,�rd� LicenseeNNo.J;57� Phone a��3✓ TYPE OF WELL/PUMP: - KNEW WELL ❑ ` "WELL REPLACEMENT D DESTRUCTION Ll PUMP INSTALLATION ❑ `}SYSTEM REPAIR�❑ ' 'OTHER L' ` - DISTANCE TO.NEAREST:. SEPTIC.TANK. SEWER LINES,;. -ADISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` ❑ ,Industrial U'Open Bottom 0 Manteca Dia,of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack C7 Tracy Type of Casing Specifications - -[-1 - f lPublic l l Other I J ,~ Delta Depth of Grout Seal p Type of �} -- I'I Irrigation-M -- ° Approx Depth-r-•i I Eastern- --! Sudace Seal-Installed by Repair Work Done 11 Type of Pump H.P, State Work Done^ _. yc Well Destruction ❑ Well Diameter Sealing Material (top Wl $ ..z .... _- ,_ -Depth• -:*-�. - -•--«..Filler Material (Below 501 - a TYPE OF SEPTIC WORK;,. NEW INSTALLATION 11, REPAIR/ADDITION I DESTRUCTION 1 11 INo septic system permitted if public sewer is Installation will serve. f3es+dence I Commercial_, O available wrth�n 200 feet:) -- ,_ € .. - - _ the. — r 14r Number of living units: ' Number of bq&ooms Y Character'of sort to a depth_of'3"feet: - "'Water table'depth! -`- M „SEPTIC,jANIC n�- ._I .p',_Type/Mfg - Capacity--',No. CompartmentsA. -• PKG. TREATMENT PLT. ❑, Method of Disposal " Dlstanceo n tea{esfC` Well Foundation Property line ' LEACHING LINE ngtoset Total length/size. --_,. �... .. = .. _ _. FILTER BED: ! ❑" 'D+stance to nearest ..well'= Foundation"` "-''PropeRy Li6b SEEPAGE PITS ; 1=Depth ILL Size- L r _ Number SUMPS k "Ll Distance to"'Wdist Welf I,�, `J r FoundationLine 0 r ` DISPOSAL PONDS '❑; 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-Local-Health District. Home owner or licensed agent's signature certifies the followirig: `'1 certify that'in the performance of the work for which this permit is issued, I shall not -=•employ any-person in-such manner as�o become subject-to-workman`scompensationiaws-of-Califomia:"-C6ntractor's hiring or sub-contracting signature - - hall employ persons subject to workman's compensa- tion_ . p -w -- certifies the following: ','I certify that rmthe performance of the work for which this permit is issued, I s The applicant ust call far II re ire ins Complete drawing on reverse side. - tion-laws Of- The Ealiforn+a:"•-•- •+ - r - - -• , pp inspections. Campy -r + Signed X w ' Title: . - _ Date: FOR DEPARTMENT USE ONLY 1 A lication Accented b P P Y Date Area 1 s IPJt'or Grout Inspection'by ' F Date J Final Inspection`by Da a � Additional Comments: !' r ❑ 'Stk .466-6781; p odi-369 3621 El-Manteca- 823=7104 ❑ Tracy'835=6385 c Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.-Hazelton Ave.,'P.O.' Box 2009, Stk., CA 95201 "'FEE ...- - .CK INFO AiV///I��OyyyUfNTMDUEGA'NIO`UNT REMITTED`°� CASH _RECEIVED BY .. DATE PERMl7N0. t-EH 13-24 iREV.+iH51 /Jif .' ... �V sLJ ._� �� x. y �•. - ��}} EH 14-26 i� II