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APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA ' Telephone.(209) 466-6781 PERMIT EXPIRES-TYEAR FROM DATE ISSUED- r (Complete in'Triplicate) u - 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 H 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 i Local Health District. `"- � , L Job Address, 37 nITA6 F- AVe City ��C _ Lot Size 1 �1 2 /T�+�S PM Owner's Name ` 1 uA Address �) Phone Contractor _Address TT(>J Ve License No.143M)l Phone 3473'15 t9Y j .TYPE OF WELL/,PUMP: NEW WELL"❑ WELL REPLACEMENT ❑ ;" DESTRUCTION ❑ A i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ~ .DISTANCE.TO NEAREST:' SEPTIC TANK' SEWER LINES DISPOSAL FLD. PROP. LINE — FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' Cl Open Bottom Dia. of Wel! Excavation ❑ Manteca t �ndustrial Dia. of Well Casing !' f� Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing / _ 5pecificatib s l r - i.,.f"1 Public fT Other. . C Delta r Depth of Grout Seal Type of Grout I I Irii anon - 9 ..App f I Eastern Surface Seal Installed by `� o Repair Work'D&4 L❑ ` Type.of Pump <H:P. State Work Dorie� Welf.Destruction ❑= Wel! Diameter Sealing.Mater6l (top 50'I / Depth r Filler Material f Belo 50') f TYPE OF SEPTIC WORK: NEW INSTALLATION t l REPAIR7ADDMON DESTRUCTION-i-I,-(No-septic system permitted if public sewer is f available within 200 feet.) ?Installation will serve:` Residence Commercial "!"' Other` - l 1Number'of living units: Number of bedrooms Character of soil to a depth bf 3 feet: *s Water table depth " SEPTIC'TANK ❑ Type/Mfg Capacity-:n • " No. Compartments . 'PKG. TREATMENT PLT. Ell � - •.� I ' Method of Disposal Distance to?nearest: well Foun'datio i w , Yr , Property Line LEACHING LINE ❑ No.& Length bf'lines k" Total_IengthLsize FILTER BED ❑ Distanca��to nearest: Well )Foundation Property Line SEEPAGE PITS I'1 Depth _ 5ize F' I Number _ C.SJMPS Or Distance to neares�:;'� Well !DD • Foun;da on 3-c Property Liner r a+� .DISPOSAL PONDS CIt ,r.� I hereby certify the[I have prepared this application and that the,wo_"rk will,be done in accordance with San Joaquin county ordinances, state laws, and ' -rules and'regulations,of-lhe San Joaquin Local Health-Distrrct- ;" ,' g '• f y , Hama owner,or licensed agent's signature,cern Ips the following 'I4ci3rtify that in the-performance of the work for which this permit is issued, I shelf net employ any person in.such rnanriei as to bedome subfeci t6.workman's compensatior laws of California."Contractor's hiring or sub-contracting signature certifies the following: "Ir certify that in the performance of the work for which this permit tion laws of California." "is issued;i shall employ persons subject to workman's compensa '�. " Y -The applicant must call for all requtr inspections. Complete drawing on reverse side. 'Signed X �I�S?i ,,. we'. r Q .. r t''� - _Title:. 1 Date: 7' v / s FOR DEPARTMENT USE ONLY Application Accepted by Date .Area 1 . . � Pit or Grout Inspection by Date Final Inspection by ! Date Additional Comments_: ❑ 5tk 466-6781 r 11 Lodi 369-3021 f] Manteca'`823-7104 '❑ Tracy .835-685 Applicant- Return all copies to: Environmental Health Per'mit/Services.1601 E. Hazelton Ave.,,.P,O. Box 2009 , Stk.,CA 95201 1 i � '• a+-" ', �:,• ' - .. - FEE -..�-_,_.,-.,�_..�.,-..r-_ - „_-_. ��.....�n-,•�•—�:.-.-.--.,.�...e�„•�»-,_ __�.---:..,. INFO AMOUNT DUE :,/ F AMOUNT.REMITTED, .CK` RECEIVED BY H DATE pERM1T'NO. EH 13-24 iREV.T i n 51 ��{) w r[,(�. f rr __ f Gh EH 14-28 � 1.60