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j r w _ i _. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT j 1601 E. HAZE'-TON AVE., STOCKTON, CA Telephone (209) 466-6781 t 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 Ryles and Regulations of the San Joaquin Local Health District. HAVY �-77 • ,,-LA-' • Job Address It 'jr=7. 011W,AV Y j4� p�' City Lot Size ° _ PM r Owner's Name Address IJNaxsV Phone CSL/ Contractor-il �� Address` License No. Phone TYPE OF WELL/PUMP:' NEWWEL"L ❑.+` WELL REPLACEMENT_.. r �V DESTRUCTION ❑ f PUMP INSTALLATION-0 f SYSTEM REPAIR ❑ OTHER ❑ 1 �J w , i DISTANCE TO NEAREST: SEPTIC,TANK+ _ SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION' '� AGRICULTURE WELL 'f OTHER WELL— ! PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA :CONSTRUCTION SPECIFICATIONS a i ❑ Industrial ❑ Oen Bottom ❑-Manteca Dia.(of Well Casing. { _ p _ �, �Dia. of Well Excavation ❑ Domestic/Private-" ❑ Gravel Pack _ -0-Tracy ST - µT j � , ype;of Casing - - -- --- •- Specifications-^- - i ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout n I' �❑ Irrigation - ---Approx. epth ❑ Eastern_ ,; Surface Seal Installed by Repair Work bane-�,❑ 'Type of Pump ."- 3 Aj H.Pe- " State Work Done ..,.,.,._Well Destruction— ❑,.. Well-Diameter.. y .. Sealing Material Itop 501 Depth Filler Material lBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is � available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms i r Character of soil to a depth of 3 feet: Water table depth ► SEPTIC TANK ❑ Type/Mfg -Capacity—' No. Compartments PKG. TREATMENT PLT. ❑ R Method of Disposal / Distance to nearest: Well Foundation" Property Line C LEACHING LINE ❑ No. & Length of lines { Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' f 4,W - WSEEPAGE PITSK Depth Size _ Number 5UMP5 ❑ Distance to earest: Well .__ Foundation AIV V� Property Line �� DISPOSAL PONDS ❑ W +-- -i hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances;"state laws, and " r rules and regulations of the San Joaquin Local Health District. p 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." Contractors 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." a The applicant must call for all required inspections. Co plate drawing on reverse side. Signed xi2221 tC&—b ��Sr?1<3 Title=�' r Date: ]]] FOR DEPARTMENT USE ONLY Application Accepted bykn Date Area Pit or Grout Inspection by le A,A q Date D Final Inspection by Date 6S Additional Comments: s tk 4664781 .-17 Lodi 369-3621 ❑ Manteca 823-7104 Cl Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE i INFO- -.-.-AMOUNT DUE AMOUNT.REMITTED "-CASHS � RECEIVED BY � y.DATE„ _ �PERMIT.NO .-. _ t A + EH1 -24iREV.t/e51 � � / ,� �/� EH 1426 � / '"' " 7