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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 CZ ! PERMIT EXPIRES T YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Heap 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. Job Address ( 12q W . 114" ST CityT�_ Lot Size PM 3M V%A-4*jC1--LA Aenys�cA- 9 ser-.61 Owner's Name Address Contractor Address License -afn OA-1-4 b TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT O DESTRUCTION O �� p PUMP INSTALLATION O SYSTEM REPAIR O OTHER�ffy�d"y��.AGi fV a DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing .l`Off ❑ Domestic/Prime ❑ Gravel Pack ❑Tracy Type of Cmngj�� Specifications[ l'1 Public n Other In Delta Depth of Grout Seal 4-S / Type of GrouT ' I I Irrigation Approx. Depth I 1 Eastern Surface Seat Installed by4>_9T dLt04-S UL&Mkx— _ Repair Work Done O Type of Pump H.P. State Work Done WON Destruction ❑ Well Diameter Sealing Material Itop 501 Is Sunt i Lt__ Depth Filler Material(Below 5(r) TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/AOOITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serer: Residence` Commercial_.. Other Number of living units: Number of bedrooms Character of sod to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. C PKG. TREATMENT PLT.❑ MethodMENT Distance inn to nearest: Wee Foundation Property LaEIn— u e n LEACHING LINE ❑ No. &Length of lines Total length/ ' 1992 G 4•s FILTER BED ❑ Distance to nearest: Well Foundation P NJ �'QQUIN COUNTY XVW N—SERVE SEEPAGE PITS I I Depth Sift Number '- DIVISION SUMPS L1 Distance to nearest: WON Foundation Property Line 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 ruler and regulations of the San Joaquin Local Health 06trict. Home owner or iicaneW agwWs signature certifies the following:"I certify that in the performance of the worts for which this permit is issued, I shelf not employ any person in such manner as to became subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature certifies the follgwing:'h 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 appNcarrtV>0 a . Complete drawing on revere side. Tde:�aCS7— Dom• � FOR DEPARTMENT USE ONLY Application Accepted by !/ Q '=L oats ` LIZArea ut Pit or GroInspection by Epi(fie•� Date ! Z Final Inspection by AWS Date C0// [ Additional Comments: O Stk 469-Ml ❑ Loc 3W3621 ❑Monte= 823-7104 ❑ Tracy 835-6386 Applicant-Return ON copies to: Envifwwn ntal Health Parit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 11PH AMOUNT IUJE AMOUNT REMITTED CCK 0 AH RECEIVEO BY DATE PERMIT-NO. .ENtl2r/REV.I/e si /^U 1� � / �7 EM:4.21 lJ f�• 4