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t , C APPLICATION FOR PERMIT SAN JOAaUIN'1LOCALIIHEAM DISTRICT 1601 E. HAZELTON AVE.,-STOCKTON, CA ; Telephone (2091-0613'767 } PERMIT EXPiR15S''1'YEAR FROM'-DATE°ISSUEDf ')rr 11 {Cnfiiplkiii in";7'ripl1cate) Application is r� 1)i::. ,;r..,�.�krt�+- -'.:' . ,k•.'i•., ..:, , ,• -'�� 'r �}6IS M'�'.r♦� L•fi+�'IJ*3r:"�'�'.'•t:•;,� hereby made to the San Joaquin Local Health District for a permit to construct and/or irtmil the work herein described.!Thk application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No,.1$82 for well/pump and the Ryles and Regulations of the Sart Joaquin Local'Health'Mitrict. DI's - I,r - :r.. + ' 4a. "1, r .•i. Yy ? ''s-p-, 5r yv'. �� , r'ct241. 'ri: �... •S' - 'vi ry '.tJ''p'- S t.srtt0 - sr Y .- titu7.7 F fV) . r.l• 'Grl ,'Z 4.'1/.?G., /% a t: .�IN :.' I. City �`ls1ArTG b'Lot Size ��r« PM Job Address ~ 4i.iI& f7 fs r •:: Owns qq rrs Name- r�H Y'd J k W1'A Se.-=Address' S/fi'IC= - -- — Phone z Contractor j snri Addcess. .�b�.��l.l%D11�arle>tT`t�... TYPE OF WEtt/PUMP: NEW WELL ❑, WELL REPLACEMENT Q DESTRUCTION [J PUMP.INSTALLATION E� SYSTEM REPAIR.E] . OTHER O I DISTATJCE TO NEAREST: SEPTIC TANK I SEWER LINES s DISPOSAL FLD. PROP.,LINE i FOUNDATION J AGRICULTURE'WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ;PROBLEM�AREA CONSTRUCTION $P1 CIFiCATIONS ❑ Industrial ❑ Open Bottom ❑Manteca Dia-nf•Well Excavation Dla.of Well Casing EIDVstic/Private ❑ Gravel Pack-. .Q: .Type of Casing Specifications C7 Public ❑ Other. ❑,Delta Depth of Grout Seal r Type of Grout ❑'Irrii)ation --Approx. Depth ❑�Eastem Surface Seal Installed by _ RepeirlWork Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter, '• Searing Material Itop•50'1 I f Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1(I,,- REPAIRIADDITION ❑ DESTRUCTION D�:INQ.septic system permitted if public sewer Is E k) Vk s wailsbli§�,vthin 200 feet.) Installation wail serve: Residence�A Commercial_ Other i1� ' >9A•i-0 Number of living units:'_ Number of bedrooms 'Qf Tj Character of soil to a depth of 3 fee', SI�A/C✓ Water table depth SEPTIC TANK a Type/Mfg . CPAIC. Are CAsT Capacity.,LOQ0 No. Compartments x .PKG. TREATMENT PLT.❑' sY. Method of Disposal Distance to•nearest: Well •FAundation pr6?m�rty Line Xft LEACHING LINE 13.1 Nor&Le gtlt of lines r " �' 'dotal Jeri,thlsire 6� FILTER BED 1-1 �t]it"ance'ta nearest: Well y Foundation AOp Line rty SEEPAGE PITS. C1 -Depth _ 'Size Number 1 � � ~. O J. c_�-h--moo r^...^•-..._.�..-�..,.,� Pro SUMPS fid Distance to nearest:_ Well ss Foundation: rty Line,. , DISPOSAL PONDS L3 —� I hereby certify that 1 have prepared this applicatbn-Itndthat-the-WOW-WHI-bb fiUnein accorda`rT'a with San-Joaqulh cduMy ordinances,state laws,and ' rules and regulations of the San Joaquin Local Health.District.. , i 1-x�A F Home owner or licensed agent's signature certifies the following: "I certify that In the paKormMAtlee of tlta for which~thf9 permit is issued,1 shall not employ any parson In such manner as to become subject to workman's cdmgeryrsa6b>�i.lawa of C1gifomia."Contractor's hiring or slrb-cotitracting signature certifies the following:"1 certify that in the performance of the work for which thw permit Is issued,1 shall einWoy,persons subject to workman's corrrpensa- tion laws of Celifomla.'• ii plicant must The apall for all required inspecti ns. Complete drawing on reverse side. Signed X / _ . . — title''" _.��"_'�'�" I f _.y. .-f _.. ._ - Application Accepted bye• __, _ 'D'ate Area i _ ." I } Pit or-Grout Inspection by — Date"' " ' '' " -Final Inspection hy. Data Additional Comments: { r ❑ Stk 466-6781 ❑ Lod 369-3821 ❑ Manteca 823-7164 r . ElTracy SZ-6M f App!"ream Return 11 copies m: Environmental Health penriit/Servilal ces E. Haze ct,'Ave:, P.O. Box 2009, Stk., CA 55201 5 i FEE AMOUNT DUE. AMOUNT REMITTED ., _--CASH _-•RECEIVED BY�.. . "DATE'.. 1 .PERMIT N0.' =-INFO � ' a' EFF 4428 EK11+26 FREV.t16 e) .� - - 1 - •. 1 Y�.� R.b. r -� i .- 'rC ♦ O O. F.. r.. 'fir 9 1 4