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_ APPLICATION FOR PERMIT AN JOAQUIN LOCAL HEALTH DISTR1C�f DEC 11 ICZ9 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ENV. IR,'D : .LNTA.L FIEALT H PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FERIVIIl(SERVICES (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. Job Address / / � n i d.✓ E ��/O KU/M t ST<LtF City 4m"<,4 -L Lot Size PM n ./ .4>� P-.t �fl�� J�p�.�,<o'� rA Phone 1107 y6L:s9 Owner's Name Address / //�� / u,. d License No.C'r"}-SS"Y94 Phone «P'�t Contractor 7 lHNw=.��f Address TYPE OF WELL/PUMP: NEW WELL KWELL REPLACEMENT CIDESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑/Nrs+z�"�sr.7 Als'0C � DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE — �wN� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation b f 0� �T Dia. 01 Well Casing y aa/ 1� ❑ Domestic/Private Ill,Gravel Casing Specifications Gravel Pack ❑ Tracy Type 7 of Grout ['1 Public (_1Other 94 Delta Depth of Grout Sealw Type I I Inigation —Approx. Depth I I Eastern Surface Seal Installed by z_i - Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 stem TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I iNailabhseptic syn 2W feet-t) it public sewer is Installation will serve: Residence_ Commercial_ Other Number of living units: — Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Method of Disposal PKG. TREATMENT PLT.❑ Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/sue FILTER BED ❑ Distance to dearest: Well Foundation Property Line SEEPAGE PITS 1 I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 1 rules and regulations of the San Joaquin Local Health Di3trict. / Home owner or licensed agent's signature certifies the following: "1 certify that in the performance rn the work for which this permit is issued, I shall not signature employ any person in such manner as to become subject to workman's compensation laws ss California." ploy persons er osnsrsubj cring rt to workman'scompensa- certifies the following:"1 certify that in the performance of the work for which this permit is issued,I shall employ pe tion laws of California" The applicant must call for all to 'red /i9spections. Complete drawing on reverse/side. /� � ! �! Title: Date: /54 Signed %�z,frts OR TMENT USE ONLY z� Date ea J - Application Accepted by � _ ft Pit or Grout Inspection by DateF--f= y_ Final Inspection by Date G Additional Comments: �/ ❑ Stk 486-6781 ❑ Lod' -3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 Applicant- Return al nvironme al Health Pe t/ "ices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 �~ FEE K RECEIVED BY DATE PERMIT NO. INFO AMOUNT DUE AMOUNT REMITTED H . EM 11241REY.1rx5r - . O� 1�1g \/I O Q-�O EH 1420