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4 IGlell.}e,�c�,�v�c. �� :a Sk�cTD AF LIGATION FOR PERMIT R3- 41b lg - o 1 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 Rules and Regulations of the San Joaquin Local Health District. 1 G 4 1 Job Address _71�0� G 11�1L+rw Dass} (NEf��° .s�j2 ��.. ,.�.L Lot Size j4<• PM H Owner's Name rz rG.4�VI�i S'�'Yi2.� Address ('1 5-46,��ss M*JZ#" 6Pf Phone - Contractor 5,PGrr;;`ryw2 Address Zg ZS" E I�'i yf' l`e License No. 51 LZCi g Phone 4/6 S-Ell TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER fJQ �9gp+� Q�-�qqS DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1 SO' DISPOSAL FLD. PROP. LINE V 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ( ��O 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of~Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Peck ❑ Tracy Type of Casing --� Specifications I'1 Public CI Other I L.1 Delta Depth of Grout Seal 4e 5E70 Type of GroutJJ 1 I Irrigation —Approx.-Depth I 1 Eastern Surface Seal Installed b,� - t Repair Work Done ❑ Type of Pump - H.P. State Work Done _ V Well Destruction ❑ Well Diameter Sealing Material (top 50') 6 Depth t Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIR/ADDITION I I DESTRUCTION I I (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 Character of soil to a depth of 3 feet: ` Water table depth 1 SEPTIC TANK O Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. ❑ i - Method of Disposal Distance to merest: Well Foundation Property Line r 1 -+ r Total fen LEACHING LINE ❑ No. 6 Length of lines 0th/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth I Sue Number SUMPS L) Distance to marest: Well Foundation Property Line DISPOSAL PONOS ❑ ( I hereby comity that 1 have prepared this application and that the work will be done in accordance with San Joaquin county orainaoces,_state laws, and rules and regulations of the San Joaquin Local Health Di§trict. 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."Contractor's hiring or sub-contracting signature certifies the following: "I candy that in rho performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applica u t call for all require in actions. Complete drawing on reverse side. ��( p�L Signed X�, Title: /��f L ' Date: NNDU LE/ FO�R6[,(lp.�E.P�tA�RATIVIENT USE ONLY _ Application Accepted by —fir _ Date /—��p�r ,,,,,,Area Date Pit or Grout Inspection by Date V Final Inspection by + t 2 � Additional comments: ❑ Stk 4666781 O Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I IFNFFEO AMOUNT AMOUNT RE 1TED CASH RECEIVED By DATE PERMIT'NO. �.EH ra.2t leEv.vxel • � �- 7U 2c v -IS-96 q d -5U S EH 147e 1 FA