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a f AY 2 1 ...;s ,APPLICA�ATIObN FOR PERMIT 2 4 SAN JOAQUIN LOCAL HEALTH DISTRICT .ENVIRONMENTAL HEALTH y 1601 E. HAZELTON AVE., STOCKTON, CA fERMITISERVICES TelepFione'�12091�466-6781 i' 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. Job Address ��/ [z l z 72 D A F City AOA' ?P4 Lot Size 440&1" PM Owner's Name JZ,15-R Al 4//E R.,P,4 Address SLm6 Phone Contractor Fra we E Ir/6+D2) Address 7 Al dl>,Z4 ,07- Ar/ License No. 41Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ - �PUMPANSTALLATION ❑ SYSTEM REPAIR ❑ OTHE ❑ ( �. DISTANCE TO NEAREST:;SEPTIC TANK' _ '� SEWER LINES, DISPOSAL FLD.�R�PROP. LINE FOUNDATION " � AGRICULTURE WELL: . OTHER WELL PITS/SUMPS ` INTENDED USE TYPE OF WELLJ PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open— Bottom ❑ Manteca Dia. of Well Excavation Dia'of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing11_-�—SpecificatidliJ ('1 Public ID Other ❑ Delta Depth of Grout Seal � � ) Type of Grout I I Irrigation —Approx. Depth I 1 Eastern Sudace Seal Installed by - Repair Work Done ❑ Type of Pump H.Pte'%- ,1C� 1 State Work Done_ Wall Destruction ❑ Well Diameter -Sealing Material (top 501 E } Depth � Filler.Material'leelow 50'1 - TYPE OF SEPTIC WORK: NEW INSTALLATIONI I REPAIR/ADDITION DESTRUCTION 1 1 (No septic system permitted if public sewer is / } available within 200 feet.), t_. ;f Installation will`serve: Residence_ Comfnercial_ Other Number of living i1hits:? Number of bedro mo s�� r1 I /\ r+✓ /��+� V ��/�� Character of soil to a depth of 3 feet: CLAY LOXarn 1 r Water table depth SEPTIC TANK t ❑ Type/Mfg ISK15)7z/E Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 / Method of Disposal Distance to nearest: Well Foundation Property Line t � LEACHING LINE No. 8 Length of lines /00*'* Total length/size /DO�.YZ 'FILTER BED ❑ Distance to nearest: Wei Foundation 440 1 Property Lim 7Sz SEEPM�S—AGE PITS I/( Depth\ ` 'S-S Size ?v� Number SU __�. -...--L7-Distance tmnearesC rwall -g0 Foundation Z 7S Property Line 7S' -- DISPOSAL-PONDS G� 1 hereby certify that hliave prepared this application and that the work will be done in accordance with San Joaquin counlyy oanai; eZ, state laws, and rules and regulations of the �an Joaquin Local Health District. �- __Home owner or licensed agent's signature cerilfies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person iSsucTi 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," _ -F- —• Ap T The applicaht mus[calf for ell required inspections. Complete drawing on reverse side. Signed xlC ra. Title: (,.A1"'S�ti Date: S,-2-917 F R DEPARTMENT USE ONLY C� Application Accepted by Date S—Zy [S Area ON or Grout Inspection by Da a Final Inspection bye LY/P/4�/GfiY� Oat r Additional Comments: O Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 10 Tracy B35-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 NFEEFOAMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT NO. w �„-��'�