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- APPLICATION FOR PERMIT SAN JOAaUIN'LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES1'YEAR-FROM'DATE ISSUED' (Corr pleteln 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.' • _ � t x . .� , . '� . - •;� _ -.. � it��_X I S T'/.d/� .iLoT of'�:�p,�j Job Address /0 111 S:""`S oOA L.:.l.__gt4---. Cit r/�lA�t/7 GA Lot Size _ �G PM L: �,�; y- ..::�' a „ .!" .y. G,. �''rF...;�'�„iY.{? " -.r, v'•k 7;w .,Lir. Owner's-Name l Lta"L),, -R nAJSo•✓ Address ;2-42S%;L— -(�F ✓W-,41 ,S7 �i[�one �3 LContractor FL.m yD �L. &A(—_Address_60-Y— AJ, j0_- LAS_.�,6License No. Z/YS�h&. -Phone- ' TYPE OF WELL/PUMP: Y NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑. OTHER ❑ q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES � DISPOSAL PLO. PROP. LINE f 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy -Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout �❑ Irrigation -L—Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done f Well Destruction ❑ Well Diameter Sealing Material (top 50'1 t Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is t r,a available within 200 feet.) Installation will serve: Residence-Commercial.=,ROther- t f Number of living units:� Number of bedrooms^ Character of soil toe depth of 3 feet: ._,:574`.,V1>y Water table depth SEPTIC TANK O thType/Mfg 0_(1 �^ �SF-L _ Capacit`_ ^" No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ^n Distance to nearest: Well Foundation �.� _ Property Line_/eJQ J LEACHING LINE No. Length of lines 3 -0! Total length/size O A 2- FILTER BED ❑ Distance to nearest: Well_/DD Foundation _2-eP Property Line SEEPAGE PITS ❑ Depth' ' '"'Size, Number .,,SUMP-S �p-.Distance-to nearest: ,WeII� r Foundation Property Line ��1]I$POSAL_P_OND5�..Y.��❑_...---'--•_��----� ``r""`=tU '-' , _..I-hereby-certify.thli:,l-hare 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 Joaquiri,;Local<Health',District. Home owner or licensed agent's,Vg!at fi ceitifies he following:"I ceitify 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 t6eorkman's compensation laws of California." Contractor's hiring or sub-contracting signature ''certifies the follow'ing`"l 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." M The applicant must call for all required_inspections Rpmplete drawingon reverse side. e �. Signed X �� . s.� Title�ti irc.� •� . .._-- Date: h, c 3 c _ FOR DEPARTMENT USE ONLY Application Accepted by € 1• Date Pit or Grout Inspection by Date Final Inspection by r Date_L�96 k F i ]:. k Additional Comments: ",;t - # ❑ Stk 466-6781 ❑ Lodi' 369-'3621 >fAantecs 823-7,104 ❑ Tracy 835-6385 i Applicant- Return all copies to:.Environinental 6eaA Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE INFO AMOUNT DUE ,, AMOUNT REMITTED r. CASH RECEIVED BY DATE-- PERMIT'NO. ,,,r.+.Ey] -24 4REV.t/s51 --- r EH 14-26