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i APPLICATIONFOR PERMIT 111 SAN JOAQUIN LOCAL)HEALTHDISTRICT F 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ( (Complete in Triplicate) ' f 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 I 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 AdcTr ss — �/�/► �+ /tea/,[-C� )� g '/� Citi Lot Size 910`�- �d� tp,P,M� c U WL w."o V _�'f i� Gln��-«,C7 f`.""{yF� /� ``.�` `l'iZv'�/`��rU - = -Owner's Name 11 t.�1�L Address � o�n -J O _+�. 1 )e-_ sLGQ.,Q� = -Phone (og LMs y n- „/ Contract G 1-,f �.�0 Address r P. CT7( 767 o4dQ License No. 32�a�� Phone YPE OF WELL/PUMP: I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ _ _.. . . PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NE SEPTIC TANK SEWER-LINES–;— DISPOSAL FLD. PROP. LINE 4 FOU N AGRICULTURE WELL L. .r OTHER WELL PITS/SUMPS ' INTENDED USE TYPE OF WELL LEM AREA CONSTRUCTION SPECIFICATIONS ; ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation's'- Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Ty–p—eof Specifications + ❑ Public ❑ Other ❑ Delta Depth of Grout e _ Type.ot,Grout ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Inst Iled by '� Repair Work Done ❑ Type of Pump H.P. State Work Done y I . Well Destruction El Well Diameter Sealing Material (top 50') Depth /ler Material {Below 501 f TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAI ADDITION 13K DESTRUCTION_ ❑ (No septic system permitted if public sewer is available within 200 feet.) ` D' Installation will serve: Residence '� Commercial_ Other Number of living units: Number of be ooms 3 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg v Capacity -`c'N6. Compartments PKC. TREATMENT PLT. ❑ Methodof Disposal ^r Distance to nearest: Well Foundation x Prop Line F V1 r LEACWING'L--INE 2r-"No. & Length of lines Total length/size Q x _ FILTER BED. ElDistance to nearest: Well__ O r Foundation__ Property Line SEEPAGE PITS ❑ Depth Size Number ? MSUMPS ❑ Distance to nearest: Well Foundation r Property Line DISPOSAL PONDS ❑ F 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,regulatlons-of the"Sah JoaquWLtical-Health-District- ^^^–Y •^--^ -�-� ; ^� -- Home owner or licensed agent's signature certifies the following: "I certify that in the 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 Califorriia." Contractors hiring or sub-contracting signature certifies the following: "I certfy,that in the performance df�rtF�e work fo'r which this-permit cs issued, I shall employ persons subject to workman's compensa- tion laws of California.''.. The appl a t must call for all required inspections. Complete drawing on reverse side. Signed , ^' ' I! Title: Date: I,, tl 1 FOR DEPARTMENT USE ONLY q Application Accepted by Date �e 6 rea /Z_1 Pit or Grout Inspection by I�' Date Final Inspection by e Date 1-2& L, Additional Comments: I� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 [TTracy 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"ND. + EH 13-24 MEV.1/957 1 ¢ EH 14-28 .-�