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APPLICATION FOR PERMIT 1 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) t 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. t Job Address:3qoo WMM� k+l HEi6HTS. .,.,1).9,1 Cityl<:M) Lot Size PM t ! ! — Owner's Name �� 4+Address � m .__ Phone E Contractor Woom�SBA[r INCAddress d. 0 !�13License No.2 31�O5 O� Phone�6 _q 1t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SE C SEWER LINES DISPOSAL FLD. PROP. LINE E FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA A IONS ❑ Industrial ❑ Open Bottom anteca Dia- of Wel ion Dia. of Well Casingk ❑ Domestic/Private ❑ ack ❑ Tracy Type of Casing Specifications f'7 Public Other F1 Delta Depth of Grout Seal a of Grout _ I i Irrigation --Approx. Depth l 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material stop 56'1 IN Depth i I Filler Material TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITIO I DESTRUCTION (No eptic system permitted if public sewer is p� ava' ble within 260 feet.) V Installation will serve: Residence dl Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet .I. Water table depth _ SEPTIC TANK ❑ Type/Mfg C01JC*/Z.0-TC Capacityj_200 _ No. Compartments W PKG. TREATMENT PLT. ❑ r Method of Disposal L—L-- Distance t6 nearest: Well Foundation � Property Line 06' 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS 11 Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f I hereby certify that I have prepared this a application and that the work will be done in accordance with San PP a Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di$trict. 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 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." The applicant must call for all required inspections. Complete drawing on reverse side. � p Signed X Title: —FZ (�—�I�A- IS—1Date: �—19 1 1 FQR DEPARTMENT USE ONLY �` Application Accepted by Date h 11� Area Pit or Grout Inspection b / Date Final Inspection by 1yc+dC Date MA-)k Additional Comments: - D Y't4 --tc _3 i.rim fG/' ❑ Stk 466-6781 ❑ Lodi 369-362 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Ji Applicant- Return all copies rrto., Environmef tel Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2609, Stk_ CA 95201*e ult f� t cbL 41.1�f�.. 1 . l�N�*{ i SoH S-1 S w a!'/- L%.$40 5 r/es..t . 1..r fly S �a"`�peFEE �y ` a..,of INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. aGG �l� }rd +.EH 1 3.24 1 REV.t i n 57 I U�I EH 14.28 s 2,3�` �`3f ""j'ls t2/1 �