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. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT x STOCKTON, CA vb iso . i✓ IV. Telephone (209) �i1 8- .n ._. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JUN 2 v 1992 (Complete in Triplicate) ENVIRONMENTAL HEALTH Application is heieby made to the San Joaquin Local Health District for a permit to construct and/or install the work herluC4!(Tflip+pgh'geop'on is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and egu J bf�t4�F{1��GG99MM55o33q.in Local Health District. Job Address `-� S ` Ce�'Ito c'T City( `k -'IC' Lot Size PM 'h" Owner's Name / 'f (,.krl k n te-4 Ct.Address f= �i '5, W- ' S ST �or'4'�a C� ZbSr Contractor/j?4LAv4L • CrcCCr— Address 1900 P01-CW Yr License No. Phone5,1O fp rLci s TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER * S 0 i% DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 5b -I00 r DISPOSAL FLD.,,"� PROP. LINE 3e / FOUNDATION Z-0 A•r AGRICULTURE WELL N 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 A/o -f Specifications 11 Public 177 Other ❑ Delta Depth of Grout Seal 3 Type of Grout �� I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed bye R 2 Pll. I Repair Work Done ❑ Type of Pump H.P. State Work Done _ Q Well Destruction ❑ Well Diameter Sealing Material (top 50') 6 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I availaeptic s stem m rented if public sewer is le 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 Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line C DISPOSAL PONDS ❑ 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 Joaquin Local Health District. t 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, employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contractin ignat certifies Wt foil " certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's pe tion lawThe appfor all required inspections. Complete drawing on,saverse/side. Signed Title: 6'q 0 `d f I) r Date: 4 FORR DEPARTMENT USE ONLY Application Accepted by C Date Area 3 6 Pit or Grout Inspection by Date I ZI— ZFinal Inspection by Date Z Additional Comments: s— G p- 66Hi- Applicant - Return all copies to: Environmental Health Permit/Services P.O. Box 2009, Stk., CA 95201 FEE gMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO �.EH13.24(REV. EH 1426