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57 w APPLICATION FOR PERMIT � �- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE, STOCKTON, CA -K Telephone (209},466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED a (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 Ryles and Regulations of the San Joaquin Local Health District. .. 3T 3q 4 ��-�/�� ......... D city-1444"I1 x:42 Lot Size PM ? Job Address Owner's Name /W7'140NV /C CCa Address 31 T1ASSAA1 �/�. ��_= .Phone 33 Z-�- t t t Contractor Address 1"' .- ;k, License No. Phone TYPE OF WELL/PUMP: NEW WELL-E] 'WELL"REPLACEMEN-F ❑ DESTRUCTIO s PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK , Q f SEWER LINES DISPOSAL FLDPROP. LINE '-%%FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED}USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industria! ❑ Open-Bottom ❑ Manteca Dia. of Well ExcavationDia. of Well Casing ❑ Domestic/Private ❑Gravel Pack"' ❑ Tracy Type of Casing Specifications ❑ Public ❑'Other b `` >w.E3 Delta Depth of Grout Seal Type of Grout is ❑ Irrigation JApprm'Depth E)-Eastern Surface Seal Installed by f i i` Repair Work Done ❑ Type of P p;. ,H.P. State Work Done Well Destruction ❑ Well-Diameter 4 ;ling Material (top 561 j .:1 M5 LDepth Filler Material IBelow 50')> i TYPEZOF,SEPTiC-WORK: NEW INSTALLATION Ll 'REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer-is '�' available within 206 feet.l I Installation will-seine: Residence tas Ery Commercial _ Other (VuAberof livingu�n.tsI Numberof bedrooms Character of soil to a depth of 3 feet: `Water table depth SEPTIC TANK ❑ Type/Mfg! Capacity No. Compartments I r t s PKG. TREATMENT PLT. LlMethod of Disposal Distance to nearest: Well Foundation Property Line ELEL ACHING LINE - ❑ No. & Length of lines Total length/size /: FILTER BED� ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth (- Size Number ' SUMPS ❑ Distance to nearest: Well Foundation Property Line w. DISPOSAL PONDS ❑ I 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 Joaquini 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 certify 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 California." r The applicant MUSTGall forFee, quired inspections. Complete drawing on reverse side. Signed +.� Title: �w> 1� Date: FOR DEPARTMENT USE ONLY / Application Accepted by _4( Area / Pit or Grout Inspection by ! Date Final Inspection by Date Additional Comments: ❑.Stk- k466z6781 L7 Lod 369-3621. El Manteca 823-7104 EI Tracy 835-6385 Applican -t Return'all copies to: Envird mental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,.$tk., CA 95201 > 4r,�,th FEE INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"N0. v + EH 13.24[REV.i/e 5) EH W26 1^^--- _� � Q� � ,j.0 _.v� � �� 1 1i,>. S V i _ is