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APPLICATION FOR PERMIT \ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL TON AVE., STOCKTON, CA V\V 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 Rules and Regulations of the San Joaquin Local Health District. Job Address E, �� 4Ctl-ni too City Lot Size /v rYe S PM Owner's Name Z + 1*-!i AA TrAddress _1 3 f J 41:[.+c k t rt S �J-,n J i Phone q It/t^ d> 13SS .I_Sr - 12.gg® Sty k Fw► 431va1, Calf /J'�X-63 7C/5-13197 "OVor Contractor3 L 1rAy 3 Sa�,{r t~.-r"k Address 0 Iri C Y 76`7 Apel,� License No. 3=}8��G Phone 3 ! TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INST/ LLATION � SYSTEM;REPAIR ❑ OTHER ❑ � V DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL �[pp[/I.._ OTHER WELL &#!V PITS/SUMPS INTENDED,US TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O�tO �'�ObS son ` c t] Industrial [jL Open 1ottom ❑Manteca Dia. of Well Excavation 1 �� Dia. of Well Casing ['Domestic/privatie .E11 Gravel,P ❑ Tracy Type of Casing Steg � ilbGA-," p ifications IV ❑ Public ❑ Other et ❑ Delta Depth of Grout Seal S D Type of Grout c1 S 4-c4`"`r ❑ Irrigation nLf_D_Approx. Depth ❑ Eastern Surface Seal Installed by m t Repair Work Done ElType of Rump Sy6. H.P.'` r��2. State Work Done 174s-,3 Well Destruction ❑ Well Diameter I Z1t Sealing Material (top 501 { �} Depth ��A ' Filler Material (Below 501 -__ !►'�1�.wn TYPE OF SEPTIC WORK: NEW INSTALLATION R REPAIR/ADDITION ❑ DESTRUCTION ❑ (No sOptic system permitted if public sewer is 1'r h t 4,_S � k-' I nlc . 'CoA v-C, c ' /`-c � 3��,�,1./� ava4ab)s within 200 feet.) Installation will serve: esidence Commercial_ Other ' Number of living units:_1Y_ Number of bedrooms _ } Character of soil to a depth of 3 feet: Water table depth f f0 SEPTIC TANK W1 Type/Mfg 02 Nit-_5 Szpft a Capacity 14,00 t n- !No. Compartments �^+ PKG. TREATMENT PLT. ❑ i ;Method of Disposal Distance to nearest: Well Foundation I O f Prol*rty Line LEACHING LINE 5?- No. &Length of lines - 4-10 L n V Total length/size 4/0 FILTER BED r�� ❑ Distance to nearest: Well Foundation Pr4erty Line — SEEPAGE PITS 21" Depth Size 3-3 Number SUMPS ❑ Distance to nearest: Well Foundatidrlt Property Line / + DISPOSAL PONDS EltA. _. > %/ir a I hereby certify thdt I have prepared this application and that the work voilbbe done in actor nce with San Joaquin cou inances tat ws, rules and regulations of the San Joaquin Local Health District. Home owner or licens4d agent's signature certifies the following: "I card fthat in the perform nce of thg work for which this permit is issued, I shalfriot employ any person in sOch manner as to become subject to workman's compensation laws of qalifornia. Contractor's hiring or sub-con4octing signature certifies the f9llowigg:''I certify that in the performance of the work for which this permit is issuid,I shall b'Oloy persona subject to workman's compensa- tion laws of-California." The applica t call for all required iropoptk ns.;ppr tets'4rawing onyreverse side. Signed Title: (,C1/nY"' =r Date: t' 7'a W ti . t ._., -FOR DEPARTMENT-U59 ONLY t W. Application Accepe y ? Area 01 C/ o{'Grou) In§l�ec' y Date I cti y _InAZAAAN Date; .+Additional Commgnts: ❑ Stk 466-6781 . O odi 369-3621 ❑ Manteca 823-7104 ❑ Tracy� 835-6385 N t Applictrint+--Return all dopios-to: Environmental Health Permit/Services 1601 E. Hazertan Ave., P.O. Box 49W; Stk.', CA 95201 FEE INFO AM^-O�UNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. EH + EH 11428 3-24(REV.t/95) . (�� ¢.x.54 g19� lLJ 0 a `��