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APPLICATION FOR PERMIT 46 SAN JOAQUIN LOCAL HE4%LTH DISTRICT r \ 1601 E HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 `� r PERMIT EMPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Hedh District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance Ill 549 for sewage or No. 1862 for well/pump and the Miles and Regulations of the San Joaquin Local Health District. / Job Address ✓ 6 &rlll� s/qq ile, City SJOL�c �' Lot Size PM rY4/n�.r cue c[ C-7 7 Y4 Owner's Name Nn/�h 61'1 .Address 2/7S 1Y L1//`arM,9 Alm Phoneme ,+zS� !�-720'.Ar, Contractor n M14Z-'ode.' a4dE +Address282S if ��'^/`�+e.,f/: License TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER N$- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Well Casing 2 13 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casingyl$ G Specifications ❑ Public ❑� �fS� /)f>o O Other ❑ Delta Depth of Grout Seal Type of Grout ,f // C'rf' ❑ Irrigation C0--Approx. Depth ❑ Easter', Surface Seal Installed by Repair Work Done ❑ Type of Pump T H.P. State Work Done �J Well Destruction ❑ Well Diameter Sealing Material (top 5 G ern ®4/0'— /7/�7 � /l�L Depth Filler Material (Beim 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ RERAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: VM Foundation Property Line j LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wall- Foundation Property Line SEEPAGE PITS ❑ Depth --Size SUMPS ❑ Distance to nearest: WA Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 have prepared this application and the the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Distrim Home owner or licensed agent's signature certifies the followarg: "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 tomerkman's compensation laws of California."Contractor's hiring or subcontracting signature certifies the following:"I certify that in the performance oflta:trurk 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. Complegiawing on reverse side. f - ✓ Title: ��,ir� Date: 9- '?� Signed X -� f1R{ DEPARTMENT USE ONLY Application Accepted by Date 9--2161 — rea Pit or Grout Inspec' aM` Final Inspection by Date 9 �-sss Additional Comment ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ kInteca 823-7104 ❑ Tracy 83t,6385 Applicant- Return all copies to: Environmental Health PemiuSemices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT Rea14)ED CASH RECEIVED BY p DATE PERMIT"NO. EN M24IREV.1/e sl EH'WW /