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%W01 APPLICATION FOR PERMIT SAN JOAQU:N LOCAL HEALTH DISTRICT 1601 HAZEL ON AVE., STOCKTON. CA TP!ephone (209) 466-6761 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health Llano:for a pen-lit to construct and/or install the work herein daseribed.This application is made in compliance with San Joaquin County Ordinance No.544 for sewage or No.1662 for well/pump and de Rubs and Ragulatio-a of the San Joaquin Local Health District. Job Address City-e!�-CC.7140 Lot Size _._"-- PM Owner's Name- I �(_,(IF-1�11 IM430 Addre s �_�PPhan. �3✓ Contractor "r Address �L —LIC?nse No ��Phone T:'PE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ty DISTANCE TO NEAREST:.SEPTIC TANK __ SEWER LINES DISPOSAL FLD. PROP.LINE FOUNDATION _AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 15-Op.Bottom ❑ Manteca Dia.of Weal Excavation Dia.of Wu11 Casing ❑Dmnastic/Private ❑Gravel Pack ❑Tracy Type of Casing_.__ SP9cif1<atipas ❑ Public ❑Other ❑ Delta Depth of Grout Seat _ - Type of Grout_ - ❑Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by_ j Repair Work Done ❑ Type of Pump - H.P. - State Work Done Web Destruction ❑ Well Diameter Sealing.Material(IOP SO) Depth Filler Matalial(Below 1 TYPE OF SEPTIC WORK: NEW INSTAL TION❑ REPAIR/ADDITION DESTRUCTION Ll (No•2 t;c system pennittedrf public sewer is I ) ayoLLl,with.200 feet.l Installation will serve: Residence__ Commercial_. Other - p Number of living unh5:_ Number of bedro�o,ps�� I Character of sol to a do Is 3 feet: ,,.l-�-I�-.-�-��—r-�- ...�-Water table depth SEPTIC TANK Iy ;Yee,Mf9 �a"U`-'r_t�"- Capacity _ No.Cc+npettments ,f PKG.TREATMENT PLT.11I Method of Disposal . r Distance to nearest: 7 i Well��Foundation.�_ Property line 'Iotsl length/elxe _— LEACHING LINE �o. d Length of lines j FILTER BED ❑ Distance to nearest: Well�.�_ Foundation�� — Property One I QO I - N tuber SSEPAGE PITS Depth _�2L5: Size {�r I - SUMPS O Dis,ance to nearest Well Founda}ion_-1-�L-___•nparty Line_�-�Q.-_ _ � DISPOSAL PONDS ❑ - I hereby certify that I have prepared this apail<ai.n and'hat the wqk will be dona`ln accordance with San Joequln county ordinances,state laws;_end rules and regulations of the San Joaquin L ral Health Ckstrict Horne owner u licensed agar.4's signature cortfies the follow.g :I certify:het in the peRormon<e ofahe work for which this fermi[is issued,I"I not employ any person in such manner as to became subiact to vmrkmarl s cempansavon lam o.Ca!Homia.-Cant rectofs hiring or subcontmcrtng signature certifies the following:"I certify that.in the performance Y.the work for which this permit is issued.I shall employ PORIU 9 subject to workman' ornpena- I tion lam of Caldomla.- The epp9osm must for ell�r/e putted iiml actions. Complete drawing on nmer. side.Signed X , i J y�(va(/ Tit e: ✓T��• bate: _ / DEP MEN USE ONLY �J J Application Acceptod by 6p -F- ---- Data _ 6 Area .X/� ,Date 1JL� Fina!Inspection by - /Prt,or Grout inspection by.'�- ( Add'¢ionat Comments: ' - O Stk 466678' ❑ Lod: 369-3152- _ ❑Manteca 82.7104 0 Tracy S3S_P. - Applicant"ROW'a6 copies to: Env'sonmernal Health Pemin/Services 1601 E. Heeelton Atro1: ...P.O. Bax 20(T7,.Stk.,CA*.�01 5 FEE AMOUNT DUE-r-AMOUNT flEMITTED CASH RECEIVED BY. . DATE;�PERMCWNO. ._' INFO ♦FN0"(11".11a]1 FN 14.29 - .. R