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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, �A Telenhone (209) 466-6781 PER_Pl_IIT EXPIRES 1 YEAR FROM DATE_ ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Loral 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. Z :;-vJob Address _ , (DOC? ' City m'4t'u E P Lot Size 'l ��S PM Owner's NamerC , q 4 9 L oGr� c i g-2 3.9 3"1 1 Add,ess Phone Q Contractor z_M `_� �__Address 13L�, Lr rff�� License No.�93�r9 Phone 4�� S8 TYPE OF WELL/PUMP: NEW WELL ( I WELL REPLACEMENT Ci DESTRUCTION (a PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION _ AGRICULTURE WELL __ OTHER WELL _ PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM ARF A CONSTRUCTION SPECIFICATIONS Industrial Cl Open Bottom E, Manteca Dia.of Well Excavation Dia.of Well Casing C1 Domestic/Private [_l Gravel Pack Ci Tracy Type of Casing_ Specifications "1 Public f Other (-I Delta Depth of Grout Seal _ __ Type of Grout _ 1 1 Irngauon ."-_ Approx. Depth I ! Eastern Surface Seal Installed by Repair Work Done i J Type of Pump ___--- H.P. State Work Done Well Destruction Weir Diameter __. _ Scaling Material(trgt 501 —_ — Depth Filler Material(Beiiw 5011 �j TYPE OF SEPTIC,WORK: NEW INSTALLATION f i HFPAIRrADDITION V, DESTRUCTION � (No septic system permitted if public sewer is rbc available within 200 feet.) C Installation will serve: Residence &/Commercial Other Number of living units: J_ Number of be ooms___3 Character of soil to a depth of 3 feet: __ Water table depth SEPTIC TANK [I Type/Mfg __ �� T �5 _ Capacity j �C� No. Compartments _ PKG. TREATMENT PLT.[.1 Method of Disposal �t Distance to near;;,' Well '=oundetion__2 Property Line LEACHING LINE No. & Length of lines _ Total length/size__ FILTER BEG I I Distance to nearest: Well -_ Foundation Property Line i SEEPAGE PITS i I Depth .__ __ Size -__ Number _ �1 SUMPS i Distance to nearest: Well _._ Foundation Property Line DISPOSAI PONDS I T I hereby certify that I have prepared this appbcaunn and that the wL rk will be done in accordance with San Joaquin county ordinances, state laws,anC E� rules and fe;lulations of the San Joaquin Local Health District. v 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 workm in's compensation laws of California."Contractor's hiring or sub-contracting signarue„ certifies the following:"I certify that in the performance of the wore for which this permit is issued,I shall employ person:subject to workman's compensa- tion Yui laws c1 Calif�cma." � The applrcan II for all re Brod ins 'tions. Complete dr;wing on reverse side. S: ned X_ - — - -- Title - -Cx,cJrJt(L_ ---- - — Date: J 9J r FOP DEPARTMENT USE ONLY 11 Application Ar,:eptea try �..,.._�,UN 0 .-___-- -.. . _---------_----- Uate_�..---1 Ara. Pit or Grout Inspection by ___--__ Odle -_ Final Irspu,.t,on by Date / Additional Comments: Sti, 466 6781 L 245 369 3621 rAant�ci 823 7104 :-: Tracy 1:356385 Applicant - Retu.n all copies to: Environmental Hedlth Perr:rt%Services 1601 E. Hazelton;-o, P.O. Box 2009, Ctk_ CA 95201 r, _ Ea tAOU.4T DLE AMOUNT H,:Mi TTED NFOCASt�_ HECEiVED BY TATE PERMIT NO r .\ EH 1124'REV EH i�26 •fico._`:'t��' —- -�_r._r..._�_. .�q� _