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APPLICATION FOR PERMIT 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 hi made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for well/pump and the Rules a la u n Local Health District. � i Job Address u ` 1 VC;Rkyp"s Ci �Lot Sue PM Owner's Name t)A zcz W•�!�` � Address,169&> 61,n./Al2A,0 Rb• Phone .G/TTifJ�p i4 . Contractor �� i " 3 Address/',�i � R Lit: License Ho. 5 2-3 Phone TYPE OF WELL/PUMP: NEIN WELL if WELL AEPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION A" SYSTEM REPAIR ❑ OT ER ❑. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES/ DISPOSAL FLO PROP. LINE d� _ _ _ f FOUNDATION _ AGRICULTURE WELL r~'3� OTHER WELL PITS/SUMPS ATENDED„USE T ^TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! ❑ Inoustrial ❑ Open Bottom Manteca Dia. of Well Exca tion Dia. of Well Casing12 Domestic/Private Gravel Pack ❑ Tra T r4 �[ cy Type of Casing Specifications ❑ Public ❑ Otper ❑ Delta Depth of Grout Seal d Type of Gr” ❑ Irrlitgation /-?�pprox. Depth ❑ Eastern Surface Seal Installed by Repan Work Done ❑ Type of Pump N.P. State Work done Well Destruction © Well Diameter Sealing Material{top 501 i Depth Filler Material {Below 501Lr. {{{ TYPE.OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION O (No septic system permitted if public sewer is I j 1•,, - available within 200 feet.) Insialtation will serve"i$esidehce � mercial_ Other Number of living units: Number of". oms F Ch R9 ter of-96il-tb--A--depot-W3:fee3: Water table depth SEPTC TANK ❑ Type/Mfg _. _ Capacity No. Compartments F PKG. TREATMENT PLT. ❑ `.. ,� Method of Disposal Distance to nearest:fl' Welt Foundation Property Line LEACHING LINE ❑ No. & Length of lines - Total length/size FILTER BED ❑ Distance to nearest: Well ' _ Foundation Property Line SEEPW PITS ❑ Depth; Size i5 her ` SUMPS ❑ Distance to neryest: Well Foundation Property Lire DISPOSAL PONDS Cl I hereby certify that I have prepared his application and that the work will be done in accordance with San Joaquin c unty ordinances, state I4ws,and rules and regulations of the San Joa "viii ocal Hiaaltli Distiicf: j a Home;owner or licensed agent's signatu're certifies the following: "I certify that in the performance of the work for whin h 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 subcontracting signature certi4s the following:"I certify that in thej performance of the work for which this permit is issued,I shall employ perlson�a subject to workman's cgmpensa tion laws of California." The abpli must.ca11 for all r ed i ctions. Complete drawing on reverse side. j Signe" .>/2��Z Title: I ',Date FOR DEPARTMENT USE ONLY j A li ation Accepted b r PP � P Y pate _ Area �TPit or'Grout Inspection by _ date L ,'.. �tn�al�Ins�ecnonDL Addi �. in I omments` 1 W C.C�CQ "ew. S 8781 LT-L8di 369 . r, JUlan 82 104 . ❑ Tracy 835-6M f Applicant- Return all copies to: Environ rtta!Heal Perm ^1 E. Hazelton Ave. P.O. BoxFEE INFO AMOUNT DUE AMOUNT REMITTED /CASH RECEIVED BY DATE PERMITNO.' + EH 3-24 EH 14.26(REV,t i e 53 ��r v ! ♦ c�`T1 y