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_ _ _ .. ... 'i• .- . _. , ,. n i.:'y:. .. �.a,ls•.,. \.:. . •�', �t� .:,XY..'r. tia_.i:: �'r • ,, -. ';t Wit: ;t - L 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 h hereby made to the Sm Joaquin Local Health District for a permit to construct and/or kutall the work herein described.This application n r made in compliance with San Joaquin County Ordinance No.649 for sewage or No.1862 for well/pump and the Rufen and Reguletkns of the San Joaquin Local Health District. :: •,;. ; ,. City-T Lot Size /w�f' PM n Job Address r. Owner's Name Fy�sTT Address '�— - ... _Phone Phone -f'1.TJ- Sv--Llcense No. ,. ..ContrarctOmNar+ DESTRUCTION O TYPE LUr.;:eP: 1 N WELL O WELL REPLACEMENT ❑ PUMP INSTALLATION O SYSTEM REPAIR 13OTHER ❑ a DISPOSAL FLD. PROP.LINE j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES , FOUNDATION AGRICULTURE WELL OTHER WELL PRS/SUMPS t• INTENDED I!SE TYPE OF WELL PROBLEM ARFA CONSTRUCTION SPECIFICATIONS O Open, - O Manteca Dia.of Weil Excavation Die.of WeU Casing. ❑ Industrial SpecMeatim O Domestk/Private. O Gravel Pack ❑Tracy Type of Casing - p Public O Other O Delta Depth of Grout Seal Typs of Grout W I. 1' a O Irftetion -Approx.Depth ❑Eastern Surface Seal Installed by - Repair Work Done D Type of Pump R.P: - - Stats Work Done Seafing Material(top 60') Wall Destruction O Well Diameter O f Depth Rller Material(Below 60) TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION DESTRUCTION O availabpe'wi him 2(l0 feet.) rt public sewer is i r k. r'_Installation wh,sane: Residence L_Commercial_ Other %/e/jeiv f liAvNe�r�y r Number of living unks:_ / Number of bedrooms CNersetix of soil to a de,tlt of 3 isut• L%�bT �.OA/"/ Water table depths SEPTIC TANK 10. Type/Mfg Capar'D . No. Compartments x cityljg Method of Disposal PKG.TREATMENT PLT.D ; !Ar** Foundation /o' Property Una — v ri Distance to nearest: Well kF �f Total length/size - LEACHING LINE Z No.&Length of linfm O, Line RLTIDi BED ❑ Distance to nearest: Well_7S Foundation ProPam R [ Number SEEPAGE+ S� ❑ Depth Size Foundation Property Line SUMPS"""r ❑ Dbbncetto nearest:' Well --- - ., DISPOSAL PONOS D I hereby certify that I have prepared this applicatio "an'that,he work will be done in accordance with Seri Joaquin oourrtY ordinances,-to Iowa.and te rules and regulations of the Sen Joaquin_Local Health District. Home owner l Pions of agent's signature certHies the following:"I certify that in the performance of the Irk for which this'pennit is issued,1 shall r • employ any person in such manner re as to became subOO to workman's compensation laws of Califomia."Contractor s hiring or sub-contracting sig 1 1 that In the performance of the work for which this permit is issued,I shall employ persona subject to workman's comp ensa- .? { certifies the following:" certify _. _. . --tion laws of Cal'rfanis:' r ' The applicant must for all required inspections.Complete on reverse side. Title: Date r + �I Signed X_ . _- FOR DEPARTMENT USE ONLY pplfeation Accepted by Date AAfOa ` . :. —�7 - � Date Final Inspection by 7 DOW Ph or Grout Inspecdon by _. .. _ Addi6onsl Comments:486 a - tlt 6781 D Lndl 369 3521 O Manteca 823.7104 ❑Tracy 8364= ;O S ' pppUctnt-Return all copies to: Ertviratnxntal Health Pemttt/Services 1601 E.Hazelton Ave..P.O.Box 2008,Stk,CA 96201 ~ FEE AMOUNT DUE AMOUNT REMITTED CASW RECEIVED BY LATE PERMR NO. t INFO r •BIt1]/111EV.70/01 — ..c. _._. _ .. _. . .. ��13•• $.5`� ._ _ L 1N/_ -__ --"a'wrfe�adQk'tyk�"'^y..k1S:":i!'•��iy�`I'ifi+'M•, �..�;.•< � �%+F c.�2�-'.-r.t- 'yr - ....ia e24.s::,�+ .,i.� e.^�'f�`..�I•: f.�.. � i M1.