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APPLICATION FOR PERMIT �p . 4q a =SAN JOAQUIN LOCAL HEALTH DISTRICT �. 1601 E. HAZELTON AVE., STOCKTON, CA FILE o® �Telephone (2091 466-6781 ate.,*-� �" PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r LC (Complete in Triplicate) Za l —cE3,0 _ Ol I� rGadr�wSCf-IT7�.E� Application is hei eby made to the San Joaquin Local Health District for a Rermit to construct and/or install the work herein described. This epplic oaq is made in Compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the RUIBS and Regulations at the San Joaquin Local Health District. li alt�A Bo�rct]el]113 4'Sc>tuta eZt atr X-N-LTA 1'1'ICOOOTR Clar•4:W-aj NE, tmLe W r*r City Lot Size � PM -- Job Address � - (,�fa+T ^1Piyc+ t n.i Address phone Owners Name — - -- 1 90 mGSar..�>SDf'L. Contractor a I Address R License No�Phone IrS Eta 141 TYPE OF WELLIPUMP: NEW WELL D WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP 11 STALLATION ❑; SYSTEM REPAIR a OTHER 1°11 �CiTEC11�f�1C1iL. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD- PROP. LINE FOUNDATION AGRICULTURE WELL ' 'OTHER WELL-PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom G Manteca Dia. of !n^ 8��1_— Dia. of Wel!Casing T o1 CasingSpecifications C: Domestic/Private C1 Gravel Pack [I Tracy Type r ['i Public '' fl Other 4 F1 Delta -Depth of 6a� nn Type of GroutN(5r2tE I i Lrigativn. _ ApPra�. Depth 1 1 Eastern Surface Seal Installed by t Repair Work Done L7 Type of Pump u H.P. State Work Done Well Destruction - ❑ Well Diameter,` Sealing Material(top 50'! a� t Depth Filler Materia!{Below 501 — C TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 I DESTRUCTION I I ave septic system P ermitte7public wer is ° 11 available within 20feet.l :I Installation will serve: Residence Commercial— Other �• 14 Number of living units: Number of bedrooms I� Character of foil to a depth of 3 feet: Water.tabk epth SEPTIC TANK d Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of DispQLD, Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/site i Foundation Property Line FILTER BED ❑ Distance to nearest: Weil SEEPAGE PITS I i Depth # Size Number SUMPS Ll Distance to nearest: Weil Foundation Property Line y 1 pl$P05AL PONDS ❑ pplication and that the work will be done in accordance with San Joaquin county ordinances, state laws, an 1 hereby certify that I have prepared this ad rules and regulations of the San Joaquin Local Health DiltriLt. I. SS owner or licensed agent's signature certifies the fogoviring: "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 workman's compensation laws of California."Contractor's 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 of California." L The applicant must call for all r ed inspections. Complete drawing on reverse side. Signed Title: SitrLtAliaFR Date: �IK V-41- PI F R DEPARTMENT USE ONLY Application Accepted by Date Area J �p Pit or Grout Inspection by Date Final inspection by Date q tl Additional Comments:. M L� ❑ Stk 468-fi781 ❑ Lodi 389.36211 ❑ Mani823-7104 ❑ Tracy 835 6386 c Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Ha2elton Ave.. P.O, box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I:ASH' i RECEIVED BY DATE PEAMIT N8. INFO ff�� // Q •� .y . EH 13-24(REV.114%5� iEH 14.2E