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.. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone,(209) 466-6781 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. ' Job Address Air YP-;� Sn /yA�SB& Ad city r G. Lot Size PM V Owner's Name 4.0Xeet ywe,9 Address Soo" ! Phone _ Contractor_?_!!A1y7hgHV iff°r1" Address �0,0,AA' License N0.'VY9r-0 V1 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ -- PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 13 A� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE, l^v FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS r� INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 O�n Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private L�,Arav-1 Pack ❑ Tracy Type of Casing specifications ❑ Public 16 Other ❑ Delta Depth of Grout Seal - Type of Grout ❑ Irrigation --LApprox. Depth 0 Eastern Surface Seal Installed by - l� Repair Work Done ❑ Type of Pump ti H.P. State Work Done ' Well Destruction ❑ Well Diameter /'Sealing Material (top 509 - Depth �i f Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION SI REPAIR/ADDITIONDESTRUCTION ❑ (No septic system permiiff. lic sewer is � available within 200 feet. Installation will serve: Residence L Commercial— Other. Number of Irving units:�_ Number of bedrooms .'3 Character of soil to a depth of 3 feet: ^ 'LaAM - _ - Water tattle depth>oYN 4p s•7 apacity !ZO o No. CompartmentSEPTIC TANK III Type/Mfg` Method of DisposPKG. TREATMENT PLT. ❑ Distance to nearest: Well__� oundation - Property Line �. LEACHING LINE 0" No. & Length of lines 3 9'd - Total length/size FILTER BED ❑ Distance to nearest: Well BGG Foundation /IF Property Line 's _ SEEPAGE PITS ❑ DepthNumber SUMPS ❑ Disttafice to nearest �Well� Foundatitfi""' e DISPOSAL PONDS ❑ ) I hereby certify that I haveprepared this applicaiion and that tfie work will be done m accordance with,San Joethis permit is issueduln county ordinances, state laws, and rules and regulations of tyie San Joaquin Local Health District9 -'Z1 `• Home owner or licensed agent's signature/certifies the following: "I certify that in the performance of the work f4 which I shall not employ any person in such manner as to become subject to workman's compensation laws of CQfQr(14.' Contrac, or's 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 p irsons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. !Y.11Gdfl_Z�Z1' -.. >.. Tide: .Date: J6' '�` P. Signed )C _ F R DEPARTMENT USE ONLY Application Accepted by � 0'7 Date �� / Area Pit or Grout Inspection by Date Final InDate Inspection by i r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca SM-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 ff.,tl�oq Qv��P:'648ox-�,�Stk., CA 85201 V FEE gMOUNT DUE AMOUNT REMITTED CK RECEIVED BY. .DATE' :PERMIT INO. INFO , -CASH ��^ SEH 1}24(REV.1/65) ,$ W � �/ ��Y� `'v 5��j� EH 1426