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APPLICATION FOR PERMIT `\ SAN JOAQUIN LOCAL HEALTH DISTRICT r\, 1601 E. HAZE T ON 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'tis 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. ,Q ,Q Job Address 2`V 7 't 0 ��!'�Y City LLL t��I Lot Size !p �I' PM Own'er's Name Ir-AA) /.OA Address Phone S 8 '+ Contractor Address 5 � ''� License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION$❑ SYSTEM REPAIR ❑ OTHER 0 �hDISTANCE TO NEAREST: SEPTIC TANK' SEWER SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS •. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing A' Domestic/ ❑ Gravel D Tracy Type of Casing Specifications i`l Public n Other ❑ Delta Depth of Grout Seal Type of Grout roiI I Irrigation { tr a Approxi Dept1 i hI Eastetn;, �.� Surface Seal Installedby l Repair Work Dora ❑ ' Type of Pump ' rH.P. ga 1' t% State Work Done_ j Well Destruction ❑ Well Diameter Sialing Material (top 50') 1 De thr , r Fille4 Material (Below 501 ) ,TYPE OF SEPTI WORK: N*W INSTAL4-A " REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is t available within 200 feet.) ( lnstaj?�� 'X l i. er,*-fi�sldenoe Commerciar '" tTlei t Number of h g units: Number of bedrooms — Character of stl to a depth of 3 felt: f x��, j Water table depth r �p 1_ [ SEPTIC TANK °'CT� �fiype/Mffg T' apacity !GO'D No. Compartmepts :"PKG. TREAT ©, r 3.. ,# l Method.of Disposal 1. Distance to nearest: ;, Well Foundation Property:Line _ 1 " LEACHING LINE" ISI No. &Length of lines k'"` '"` """` " Total length/size �� ~ 7, FILTER BED ❑ " Distance to nearest: Well Foundation Property Line w� 0 ( .SEEPAGE PITS I I j Depth Size _ Number r SUMPS 41 Distance to nearest: Well— 60" Foun #ion �f Property Line �+DISPOSAL PONDS ❑ -`�- i► �. I hereby certify that I have prepa(ed this application and that the work will be donq in accordance with San Joaquin county ordinances, state laws, arfd rules and regulations of the San Joaquin Local Health District. 1. i Home owner or licensed age lt'9 signature certifies the following: "I certify that in th '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 compensations ws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this perm4 is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant rust call for all rre uire in coons. Complete drawing on reverse side. Signed X `— Title: Q t.c! V a Date: ' FOR DEPARTMENT USE ON131 t _ . Application Accepted r Date �G Area ., S ;Pit or Grout Inspectiorllby Date Final Inspection¢; ate jAdditional Comments: ❑ Stk 466-6781 11 kodik AW.391Manteca 823-7104 ❑ Tracy 835 638 !Applicant - Return all copiesi,to,•�a*haaata alth Permit/Services 1601 E. Hazelton Ave., P.b. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED Cr/SH RECEIVED 8Y DATE PERMIT`NO. +.EH 13.24(REV.1/85) t� `' O `3k �d AO�Z EH 14-26 1