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bra APPLICATION FOR_PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT s-% 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 OCT ? 4 I^^A PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r),SAIV J0A (Complete in Triplicate) :t fh?0"V C HEqL : Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work erein'desl'cribed. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weli/pump and the Rules and Regulations df the.San Joaquin Local Health"District. Nell }erl m_2/ 7� I Job Address t� im- r °b tsAve�l/Oa� Blvd City.R45 �� Lot Size "' PM - C r' Rl aT'U Address 2!-1 A). LL-�111 6L_ Ave,.� _ p(2e 1 ) f q9-2 l o g Owner's Name �_�U /� /} 1 Contractor f )ri lli n Address P�O r7 � CA License No. 263- 08� Peen l�z� TYPE OF WELL/PUMP: NSW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ,, / PUMP INSTALLATION 0 SYSTEM REPAIR F-1 OTHER` MOy2ilb 01 YVe# DISTANCE TO NEAREST: SEPTIC TANK Nr� SEWER LINES SCS DISPOSAL FLO. N //PROP. LINE >S0 FOUNDATION �fl AGRICULTURE WELL�-�' OTHER WELL PITS/SUMPS Nlq INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation�/0"/!a Dia. of Well Casing ❑ Domestic/Private `Gravel Pack ❑ Tracy Type of Casing P021 Specifications 17"1 Public in Other Cl Delta Depth of Grout Seal SO j Q Type of Grout I I Irrigation 220 /gd Approx. Depth I 1 Eastern Surface Seal Installed by_pf rr ll1_.._n g:: Repair Work Done ❑ Type of Pump H.P. State Work Done_ 0 Well Destruction ❑ Well Diameter Sealing Material (top 50') M Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION ! I (No septic system permitted if public sewer available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/M g Capacity No. Compartments PKG. TREATMENT PLT. 0 Method = Disposal Distance to nearest: Well Foundation Propertv Lice a.EACHING LINE ❑ No. & Length of lines Total length/size_.., FILTER BED ❑ Distance to nearest: Well_ Foundation Property Line _ SEEPAGE PITS. l I Depth Size_ Number SUMPS Ll Distance to nearest: Well_ Foundation _ Property Line_ DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in 3ccordanc.e with San Joaquin-our1Y1, ord,'nances, state laws, and rulrts and regulations of the San Joaquin Local Health District. Hon-e owner or licensed agent's sig:ature certifies the following: "I certify that in the performance of the woifc for wh'.h this pc.At is irsued, I shall not employ any person in such manner as to became subject to workman's compensation laws of California."Contractor's (:ring c-sub"cortrzcting signature certifies the following: "I certify that in the per nrmance of the work for which this permit is issued, I shall employ person subject to wor"r:mn's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. cO [�1 Signed X ' , Title: //CS PLe �""" /' Dale: FOR DEPARTMENT USE ONLY App Pt-ation Accepted by t-.. Date Area _ Pit or Grout Inspection by t Date�yzf _ Final Inspection by.' y �~ Dated 2-ou^ r/ Additional Comments: ` ❑ Stk 466.6781 ❑ Lodi 38"'j-3621 ❑ Manteca 823-7104 ❑ Tracy 835-5385 Applicant- Return all copies to: Envlfonmental Health Permit/Services 1601 E. Hazeiton Ave., P.O. Box 2009, Stk., CA 95201 /s lV e4ZL- Cevezvj�e_CO. �K °u n.�r a"DATE =PFR INFO FEE 'AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY tM M24 fi1EV.1/ 51 q l. b < 1' EH 14-28 i 4