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APPLICATION FOR PERMIT ( � SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1601 E. HAZEL T ON AVE., STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a (Complete in Triplicate) I 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 T��7� j -�/�/� b. City _ Lot Size PM Owner's Name VA-�V CRL r-S' Address 2 Phone Contractor Addressense No., 1��Phone i TYPE OF WELL/PUMP: NEW WELL ❑ WELL RE LACEMENT-,K, DESTRUCTION �►j rjQ I PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER ❑ ` DISTANCE TO NEAREST: SEPTIC TANK ""�—' SEWER LINES �� DISPOSAL FLO. PROP. LINE �— FOUNDATION.. AGRICULTURE WELL OTHER WEL6& PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAJIONS S ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �K.Domestic/Private '76ravel Pack Tracy •Type of Casing_ "S cations f-1 Public ❑ Other ❑ Delta Depth of Grout Seat 1/x1,_ Type of Grout I i Irrigation 4w-Approx. Depth l l Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction elite Well DiameterSealing Material stop 50'1 Depth z6 _� _ Filler Material (Below 50 -_ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 2011 feet.) t� Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms t J Character of soil to a depth of 3 feet: f Water table depth SEPTIC TANK ❑ Type/MfgiCapacity No. Compartments N PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LA LEACHING LINE ❑ No. & Length of lines Total length/size > i FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS_ _ ❑ Distance to nearest: Well __ rtoundation ropdrty tine~' DISPOSAL PONDS , ❑ �- .. __ 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 regulations of the San Joaquin Local Health District. 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 California."Contractor's hiring or sub-contracting signature' certifies the following: "I cellify 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 Californi The app' nt us 11 f all requir d nspectio . Complete drawing on rev r side. Signed X Title: r Date: - FOR DEPARTMENT USE ONLY Application Jecepted Date y Area5. Pit orCr►oui;Jnspedtionby ` Date Final Inspection by Date Additional�•omt,ments: L � artiv 0 Stk 46,6-6781 a ❑!Co'di 369-3621 ❑ Manteca 867104 ❑ Tracy 835-6385 Applicant_i RlstuAn'�Il/c86iii:-,to:,Chvironmental Health Permit/Services 1601 E. Hazalton Ave., P. ox 2009, Stk., CA,85201 rrGt�f�(, 2Ri��' _ !a n-r fS C�k'du7` P�� -Old wrl{ dCS O INFO AMOUNT DUE AMOUNT#(EMITTED CASH RECEIVED BY DATE PERMIT'Np. +.EH13-24(REV.t i e s) EH 11-29 3�9A— Puh�p e_1__ ru`cQ