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g APPLICATION FOR PERMIT SAN'JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 Ryles and Regulations of the San Joaquin .Local Health District. Job Address S 71d/ ik# Cr, 'T'bs 1). " City9 !'�vn { Lot Size PM (}J((f Owner's Name V11 A; 64 85 sE?cfA-) 'Address J>e-� Phone Contractor Address—?,. l• /�1TC.0 License No.P_26�S_ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ( INTENDED�USE —,TYPE bF WELL PROBLEM AREA, CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ', ti Type of Casing Specifications ❑ Public ❑ Other ❑ Delta „.`'4bepth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern ` ;Surface`ISeal Installed by w, I Repair Work Dans ElType of Pump W.P. `- State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public seweris0O available within 200 feet.) Installation will serve: Residence_,4e_�Commercial— Other r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: —T Water table depth SEPTIC TANK iType/Mfg ��I�'L� Capacity„/—tro GAZ No. Compartments t PKG. TREATMENT PLT. ❑ } ��-` Method of Disposal Distance to nearest: .Well Foundation Property Line LEACHING LINE ❑ No. & Lengihrof lines Q C X y F Total length/size FILTER BED x r Distance tb nearest: Well lutV Foundation` Ij'� Property Line SEEPAGDPITS_..'. .'❑ ?,Depth E ; Size Number SUMPS Q Distance to`nearest: Well Foundation Property.Line DISPOSAL PONDS ❑ -4, �. ' .l.hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stab: laws, and Miles and regulations of the San Joaquin Local Health District. Honie owner or licensed agent's signature certifi s the following: "I dertify that in the performance of the work for which this permit is issued, I shall not t .: eiijploy 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 performance of the work for which this-permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." * - . The applicant must call for all required inspections. Gomplete drawing on reverse side. A Signed ~� g Title: ..__ Date: f�./IV .5-� I POR DEPARTMENT USE ONLY-;r Application - Application Accepted by DIate Area ` 1 Pit or Grout Inspection by -Date — -^'-�Final Inspection by" - °-� s ': Date Q Additional Comments: S� �'�" `1,u �� vs,,C-f (. I-- l ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 : ❑ Tracy 835-6385 ; F Applicant- Return all copies to: Environmental Health"Permrt/services 16Q1 E. Hazelton Ave:�-P.0. Box 2009, Stk., GA 95201 FEE- AMOUNT-DUE--- �-�-AMOUNT'lEmit-rED" NFO- CASH x-RECEIVED BY-'A` DALE y PEfiMIT NOS I +EH'1 -24(REY.tiie5) LiS, EH 1426 � �>f