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APPLICATION FOR PERMIT 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. ` /7D/O N �7 Job Address fLQJ7 �'7([�/J,�1 � � . CRY Lot Size Siw�u�-�_._ PM ' Owner's Name L�[S4/LLL7i/,f Address �70�(,] C. yeo Aga Phone r \ Contract ,r4tiC AddressAe)44-0,J� 7&0 7 L�License Phone' —iSIU TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑- O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES , DISPOSAL FLD. O PROP. LINE FOUNDATION AGRICULTURE WELL 2 % OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial r ❑ Open Bottom ❑ Manteca Dia. of Well Excavation of \v ❑ DomElElDia. ofWell Casing estic/Private Gravel Pack Tracy Type of Casing SpecificationsWelll , V El Public ❑ Other ❑ Deka Depth of Grout Seal'r.' Type of Grout y ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed'by Repair Work Done ❑ Type of Pump ,H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') " Depth r Material (Below ') 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPAI ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is j available within 200 feet.)/%/" / J Installation will serve: Residence_ Commercial._ Other � i Number of living units: Number of edrooms ' Character of soil to a depth of 3 feet: ,/ "L t f Water table depth SEPTIC TANK ❑ Type/Mfg Capacity."I No. Compartments PKG. TREATMENT-PLT.❑ _ _ �' Memotl of pis l � • posa' ,r Distance to nearest:—Wall---. Foundation I Property Lift — � I LEACHING LINE P-�-No. & Length of lines --/_TotaI4ength/size--- 6-- . FILTER BED ❑ Distance to marest:' well Foundation 140 Property Line SEEPAGE PITS ❑ -Depth AS Siler ."X, Q I Number -- _ _— '� SUMPS m!Distance to ne8rost' Well � Foundation � � �_ Property Line DISPOSAL PONDS ❑ .tit I r' I hereby certify that I have prepared this application and thaf the workwill be done.in accordance with San Joaquin county ordinances, state laws,and .r rules and regulations of the San Joaquin Local Health District. I I_ Hama owner or licensed agent's signature carts ies.the following: "I cerafy that ln'IA patformance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject-to-workrnen'stcompensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I carafy that in the performance of the work for which this permit is issued.I shall employ persons subject to workman's comosl tion Ism of California." `•— — — J The applicant must II Tor ell raga" din actions. Complete drawing on re�verJsej s�}da. ^/7''7' Signed% Title: I/"/ Date: U'fK o J FOR DEPARTMENT USE ONLY '^ + Application Accepted by ( i Date V Area Pk or Grout Inspection by Date O -Final Inspection by Data Additional Comments: I 'Y 4 ❑ Stk 4668781 gjLcxfi 389-3821 ❑ Manteca 823-7104 0 Tracy 83583135 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.(Ha`zelton Ave., P.O. Box 2009, Stk., CA 95201 INF SEFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. • EM 1i311RFV.lIasi ER 1430