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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT "' c ..." 1601 E; HAZEL T ON AVE. , STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 4 YEAR FROM DATE 'ISSUED (Complete in Trjpiicate) .,�,."" r> Application is hereby made to the San Joaquin Local Heahh District for a permit to construct and/or install the work herein described. This a Pica ' Z': f f made H 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: t . : pp tion is - _ : 4 Job Address �T.�4 ,s- r r"'7 Jr s. . . + Si f a{ ►+ ' City .Lot Sae i Owner's Name f`Gt !lf t, ;_ PM Address- 1 f�LQW Phone . Contractor / T r, Address , TYPE"OF-1NELL/PUMP:-- .+ -NEWELL❑ LicenseNo.- Phone`'� .�+ , VtiTELL`REPLACEMEiQT'p� "RUCTION-0--7- } PUMP INSTALLATION ❑ - DISTANCE TO NEAREST:YSEPTIC TANKSYSTEM REPAIR ❑ OTHER [DSEWER LiNES ` DISPOSAL FLD. PROP, LINE I iFOUNDATfON AGRICULTURE WELL OTHER ELL_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PiTS/SUMPS ❑ industrial ❑ Open Bottom ❑ Domestic/Private J ❑ Manteca Dia. of Well Excavation ' f ❑ Gravel Pack ❑ Tracy T Dia. of Well Casing ❑ Public ❑ Other Ype of Casing >7 - 11 Irrigation V""'x. •❑ Delta Depth of Grout Seal tel, to Specifications ---Approx. Depth ❑ Eastern Type of Grout Repair Work Done ❑ Surface Seal installed bq ,l , Type of P mp �� H.P. r T Well Destr/action ❑ Well Diam ter u r. .State Work Done De th a Sealing Material (top 50') p Filler Material (Belo 50')A} } � TYPE OF. I'll WORK: NEW INSTALLATION _ —� =- REPAIR/ADDITION ❑ DESTRUCTION ❑,(No septic system permitted if Public Installation will serve: Residence f ' # , • p c sewer is s t ! Commercial sr;rr .,available within 200 feet.) Other t _ -�=.�. Number of living units:_� Number of bedrooms _ x Character of soil to a depth of 3 feet' t✓°LAv 14+ti1 " SEPTIC TANK X Type/Mfg --Y Water table depth * -Capacity�f2 o� PKG. TREATMENT PLT. Elr No. Compartments � Distance.to nearest: - Method of Disposal We0'Q "`Foundation L r 1 i � I Property Line! LEACHING LINE '19 No. & Length of lines — i FILTER BED ❑ Distance -Total length/size lj to nearest: We� t f SQL_ Foundation / i' �Property Line�� x r SEEPAGE PITS ❑ Depth � SUMPS Size ; ❑ Distance,to nearest: Wel! NumbeG "DISPOSAL PONDS ❑ Foundation Property Line I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin rules and regulations of the San Joaquin Local Health.District u,f +• ar_a r �i �; Qin courtly ordinances, state laws, and M Home owner or licensed agent's signature certifies the following: "I ce employ an ;" '° p y y person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature that in the performance of the work for which this permit is issued, I shall not � 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." The applicant must call I -t' x "Z nspections. Complete drawing on reverse side. `Signed Title: Date: ` �1 FOR DEPARTMENT`USE 0 LY Application Accepted by '' pp Pit or Grout Inspection by 4. '# Date `-7-e16 Area Date�— Final Inspection`by Additional Comments: ¢ ate 13Stk 466-6781 'Lodi 369-3621 "'s" 14:., " '�*,< ❑ ¢ �f Manteca 823-7104 {O Tracy 885-63$5 w� Applicant- Return all copies to: Environmental Health PermitlServices 1601.E..Hazefton Ave., 0!&Box x 2009,Stk., CA 95201 FEE AMOUNT DUE INFO .AMOUNT REMITTED CK CASH RECEIVED BY DATE +FH 13-24 fillties) PERMIT'NO. EH 14-26 ` ¢t