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APPLICATION FOR PERMIT l SAN JOAO.UIN..LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM'DA"TE ISSUED (Complete in Triplicate) , r.i+; ;+�. ` A" 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. ,;, � 1p�'ef •1 !�e. '� , - w Jr City .fi h F i Lot Size It erg PM Y y Job Address - _ r� / `-Address � —`=--y-- --�-- Phone J Owner's Name , ), i' tJ License No. { �� ' iyP-hone Contractor ssm Ne _ ��— --- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT d DES TRUCTIQN 11 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _ r . .. SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST:.SEPTIC TANK. - x-- -� �� R _ FOUNDATION AGRICULTURE WELL 10THER WELL PITS/SUMPS INTENDED USE TYPE OF WELL �"-PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing VENdusir� Lln ��. ._ Open Bottom ❑ Manteca Dia. of Well Excavation T e of Casin - ' Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy yp g Type of Grout ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 6 ❑ Irrigation _, Approx. Depth ❑ Eastern Surface Seal Installed by } ' Repair Work Done Ll Type State Work Done Type of Pump Well Destruction ❑ Well Diameter Sealing Material (top 501 f Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ .REPAIR/A DI ION X DESTRUCTIO -tNu�olla pe£wlic sh tem pe200 rmitted if public sewer is _ 11nlnstallation will serve_YResidence._k�Commercial Other_ -47 -. 3 Number of living units: Number of bedrooms, 213 I Mfr �l�'t ' _ 1% - Water table depth Character of soil to a depth of 3 feet: _ T e/Mf j 'Gf Capacity No. Compartments SEPTIC TANK ;� Type/Mfg g C '%0 N Method of Disposal PKG. TREATMENT PLT. ❑ ZA/�(6 'eIL- Foundati n- �' property Line Distance to nearest: Well — i 7 ) Total length/.size i Q LEACHING LINE [ NO. & Length of lines —_ t �z FILTER BED ❑ Distance to nearest: Well/4P4 Foundation Property Cine ' �- 1 3� Number " SEEPAGE PITS �l Depth .ZS _Size1 F0 SUMPS Qf Founcfa iton__ Property-Line ❑ 'Distance to nearest: Well�.,� ,y { � l DISPOSAL PONDS ❑ t , 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. i i - - ; Home owner or licensed agent's signature certifies the following: '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 to become subject to workman's'compensation laws of California."Contractors hiring or sub-contracting signature i certifies the following:"I certify that in the parformanee 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. Complete drawing Ion reverse side. kr ' ` a Di: Signed X Title:` F DE TMENT USE O ONLY. l Date i Area Application Accepted by e Final Inspection by Date I Pit or Grout Inspection by i Additional Comments: ' ❑ Lo ❑ Stk 466-6781 di 369-3621 � -❑ Manteca 823-7104 ❑ Tracy 835-6385 � Applicant- Return all copies to: Environmental Health Permit/Servioes 160 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 > � ;n CK RECEIVED BY DATE PERMIT`NO. r " FEE AMOUNT DUE AMOUNT REMITTED CASH +EH 13.24(REV.10/83) INFO, Q f eJ b EH W26 --