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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 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 l.�l ! City Cr �1/Lot Size j �� PM Owner's Name AQ !N Address 2 p Vl< 9f� Cj tkA�� Phone 5r!A�� VYI+�EIQ �1YWdress L� (ce �� >r TYPE OF WELL/PUMP: -_ nse No. _ Phone NEW WE' WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ ' OTHER L1DISTANCE TO NEAREST: SEPTIC TANK D 6 `_ SEWER LINES DISPOSAL FLD-•- PROP. LINE FOUNDATION AGRICIULTURE WELL OTHER WELL PITS/SUMPS C INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Open 8ottom_ f]Manteca ,t ,Dia:of_Well.Excati nv O — Dia. of Well Casing Domestic/Private Gravel Pack .17-Tracy-_- Type of Casing -740 dr ' ❑ Public Specifications ❑ Other ❑ Delta Depth of Grout Sealr i 49'0 r ❑ Irrigation I - Type of rout �R&C- -_._Approx. De'ptth+ ❑ Eastern Surface Seal Installed by t Repair Work Done ❑ Type of Pump ,Voz H P., / X Well Destruction Ll Well Diameter State Work Done Sealing Material (top 50'1 f -re Depth i iller Material (Below 50') + j TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ Ft EPAIR/ADDITION ❑ DESTRUCTION-0-Hdo-septic system permitted if public sewer,is ti - �'_evailable',within 200 feet.) Installation will serve: Residence— CorrimiSrcial Other a�.1 'r 1 ' ! Number of living units: Number of bedrooms'-- Character Of soil to a depth of 3 feet: SEPTIC TANK Water table depth ❑ Type/Mfg ` Capacity 0 No'Compartments 1,10 PKG- TREATMENT PLT. ❑ '• + �r Distance to nearest: Method of Disposal _Well Foundation-� l_ O +, �j ✓Y Property Line LEACHING LINE ❑ No. & Length of lines _ *Totallength/size FILTER BED ❑ Distance to nearest: Well! ice. "' ' `� ` Foundation property Line y . SEEPAGE PITS ❑ Depth Siiet SUMPS r: Number r ❑ Distance to nearest: "- -"� % Well F6undatian Property Line DISPOSAL PONDS Cl 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 fl rules and regulations of the San Joaquin Local Health District,._., . Home owner or licensed agent's signature certifies the following: ""' r_ '^ employ an 1 "I certify that in the performance of the work for which this permit is issued, I shall not i P Y y person in such manner as to become subject o workman's com compensation laws of California."Contractor's hiring or sub-contraciing signature certifies the following: "I certify that in the performance of4he work for,which this permit is issued, I shall employ parsons$ubjeo o workman's compensa tion laws of California." --- ` r Thea licant 4AI j PP v r I require s c 'ons. Complete.drawing,on,r rse side. Signed X Title: 41) Date: FOR DEPAR M T USE ONLY Application Accepted by (G /I i r Date (� Area t.. Pit or Grout Inspection by -" D�$ --- �-� - - {- v Date Final Inspection by I Date 7-A-91- Additional Comments: c:. iij ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca •S23-7104 Q Tracy '835-6395 Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT L1UE AMOUNT REMITTED CK INFO CASH RECEIVED BY (SATE PERMIT'NO. + EH 124[REV.t/Hsl EH 14-4-26 1p/•�� }