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APPLICATION FOR PERMIT SAN JOAQUIN-LOCAL HEALTH DISTRICT 1601 E. HAZEL`TON 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 Sari Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address Cd�' � �t' '/1/ ""l�ft"ZT3)_ J� City ?C�/I�t�/!f Lot Size r ��. PM" Owner's Name J041-- "" Wd4 u Aa L Address 0,7c) ��'aY 7-!'d '� � >4r Phone Contractorlt3,&&a_.CeP, e /se�&dress f424 4Ip 3 License No. Phone SW——7y� TYPE OF WELL/PUMP: �I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ F r P. IR OTHER INSTALLATION ❑ SYSTEM REPAIR LI O -HER ❑ i V i P',� I I DISTANCE TO NEAREST: SEPTIC TANK SEWER`LINES� sDISPOSAC`FL PROP. LINE FOUNDATION k _ AGRICULTURE WELL OTHER WELL _ J PITS%SUMPS' 0 i INTENDED USE TYPE OF WELL"I PROBLEM AREA CONSTRt1CTION SPECIFICATIONS ' ❑ Industrial Ope B�rottom ❑ Manteca Dia`,of Well Excavation t ! Dia. of Well Casing pp "Domestic/Private I� GravelHPack El Tracy Type of Casing ' Specifications 1 W I `f r ❑ Public .I Cl"Other Delta Depth of Grout•Seaf'� Type of Grout } ❑ Irrigation —Approx. Depth ❑ Eastern r 76 Surface Seal Installedi by R pair Work Done ❑ Type of Pump H'P' " State Work Done { Wall Destruction ❑ %Nell Diameters i Sealing Ma erial (top150'1,'!'-0J t Depth ` Filler Ma°a aal (Below X50 TYPE OF SEPTIC WORK: NEW INSTALLATION,11 REPAIR/ADDITION ❑ DESTRUCTION ❑ fNo septic system permitted if public�sewer is available within 200 feet.) I Installation will serve: Residence—� Commercial uflber of living units:��` Number of bedrooms' Character of soil to a depth of 3 feet: Ce v y Water table depth F ' SEPTIC TANKType/Mfg c Ei x Capacity i+Zm (5 No. Compartments Z ' PKG. REATMENT PLT. ❑ ; Method of Disposal { Distance,to nearest: , .Wello .-�—*Foundation Property Line yy i LEACHING LINE No. & Length of lines - QTotal length/size �� FILTER BED ❑ Distance to nearest: Well O M Foundation -- Property Line_.4Y[J1 _0 F SEEPAGE PITS Zii IDepth ZO Size Y p. Number 21 - I I y�SUMPS C1(�'Distan4. to nee est:�. W41, " 1_�/-- ,.Foundation Property Line G&SPOSAL PONDS_ Ell sr '^ 41 hereby certify th fl,have p�'epare l this application and that the work will be done in accordance with San Joaquin county ordinances, stete laws, and (rules and regulations-of the San Joaquin Local`Health District. j C/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 1 ,employ any person in�such manner as'to becometsubject to`;workman's compensation laws of California."Contractors hiring or sub-contracting signature + certifies the following: ''I certify that inl the peifo6%ence of'the work for which this permit is issued, I shall employ persons subject to wor'kman's compensa- tion laws of California:" # 'o-Li I �d + The applicant st call for all re inspections. Complete drawing on reverse side. Sim g e�d�N, c"L�L�� J .a - _ Title:_-4lay4/ Date: 6 3 AY•chrhO e F DEPARTMENT USE ONLY C Application Accepted by !�" Date 1d ©� Area d F i / P- or Grout Inspection by to e �Y�' �� Final Inspection by ,fin .� .�+� e D C?- or Additional Comments: ❑ Stk .466-6781 ❑ L'odi 369-3621 ❑ Manteca 823-7104: ❑ Tracy 85" co Applicant- Return all pies`to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. INFO CASH ( p/ py c + EH 13-24%REV.1/a s? �� o 6 1738' G-� �� ! g�0 010+3 ': EH 14.26 J! I