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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 Triplicates 1 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.509 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin -11 Local Health District. �dd+ I go w, - Job Address _ /1239-030-08' City 1-4 Lot Size__ PM 1 Owner's Name M#SUA/G /95s6?6 LTO Address PO egif y70 G f/h ro% X5jy'9 PPh/one Contractor 6°Ltry� Address GO�✓ MYrt/t .Sf' License No� 271 Phone�lazilkIfJ TYPE OF WELL/PUMP: NEW WELL A WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEMM REPAIR ❑ OTHER X/Yfp//lrCMlp, ty[/lf, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES � DISPOSAL FLD./` f4r- PROP. LINE FOUNDATIONI—&—R- AGRICULTURE WELL &Y OTHER WELL / Y PITS/SUMPS*;&lr INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC NS) ,� ��❑ Industrial — - ,,..-. Gr❑Open Bottom _CP Manteca Die. of Well_Excavation Ola. of Well Casing ❑ Domestic/Private avel Pack Tracy -'Type of Casing YL ��# -Specifications!' ("I Public �(�y,(,}�R.��er ❑ Delta Depth of Grout Seal 20 Type of Grout-�'MeIf-e� I I Irrigation - [ r x.Depth 1 I Eastern Surface Seal InstaBed by C NS ^ 1 Repair Work Done ❑ ype pf Pump I 'I H.P. State WorklDone_ 1 Well Destruction ❑ Well Diameter r z Sealing Material Itop 50')r0 ,05 C L7/`' Nl O/rC S/✓z'/ 174 bM h Wdll Depth �b'� �1[ 5� Filler Material (Below 501 PP TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 0111111 available within 200 feet.) O Installation will serve: Residence�f kCommercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: '1 Water table dept; _ SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT.❑ I Method of Disposal Distance to nearest: Well Foundation Property Line it LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to earest: Well Foundation Property Line I SEEPAGE PITS I I Depth I Size Number SUMPS 0 Distance to nearest: Well -Foundation Property Line w DISPOSAL PONDS ❑ I 4 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 rules and regulations of the San Joaquin Local Health District. `r Home owner OF licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued. 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contrectoes 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 persons subject to workman's compensa- tion laws qf-Califgriri$:"�----- '-`•'='CjT.x -- --- - .. � - .. - � _. .. The applicant r st call far all required inspections. Complete drawing on reverse 11 side. Signed X Title: JAZ;"- Date: FOR DEPARTMENT USE ONLY _-_.__ / Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by - Data Additional Comments: ❑ Stk 4666781 ❑ Lodi 369.36211 ❑ Manteca 823-7104- ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk„ CA 95201 tFEE 1 NFO AMOUNT D(UE�`� AMOUNT REMITTED DATE RECEIVED BY DArTE PERMIT'NO. ,EH1W4ffllV.rrns) "`� •O\J tA� EH 1418 ll 11