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` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 herein described. This application is -4 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 it �� I +Vy r ,_ City L.�+i,�. Lot Size ZIP Aalc PM I, Owner's Name RRA W06bWff Address ZF37 'il/-j4.11 - Phori�v7D 77- Contractor - '�R11J,lnl�i Address.+g]f) I.0602ArF AI/5t ,License No'7� Phan41 TYPE OF WELL/PUMP: NEW WELL / WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ ; OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 70' SEWER LINES pig DISPOSAL FLD. PROP. LINE F67 FOUNDATION AGRICULTURE WELL/ -_ OTHER WELL PITS/SUMPSv , INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSIn i ❑ Industrial I El Bottom O Manteca = Dib. of Well Excavation Dia. of Well Cl/Domestic/PrivateGravel PackR p Trac y Type of Casing '/ gpecifications❑ Public r"` p Other—!ftz C�Defta��'�^—Depth.of Grout Seal �b Type of Graut❑ Irrigation _Approx. Depth 'p Eastern Surface Seal'iristalled byRepair Work DoneEl Type of PumpStfB�L�S1. r M.P. State Work DoneWell Destruction F1 Well Diameter � Sealing Material {top 50') CPQ A/%Depth Filler Material (Below 50') R2 TYPE OF SEPTIC WORK: NEW INSTALLATIONIJ REPAIR/ADDITION`O DESTRUCTION ❑ (No septic system permitted if Ty' available within 200 feet.) Installation will serve: /Residence— Commercial— Other '- ° Number of iivingkun�tsi+ .Number of bedrooms Character of soil to adepth of 3-feet l Water table depth r SEPTIC TANK ❑ Types/Mfg ` , '1 'moi Capacity No. Compartments l i 1 PKG. TREATMENT PLT:CJ # r Method of Disposal I { Distance to nearest .WeII Foundation Property Line LEACHING LINE }Q No. & Length/of lines Total length/size ° FILTER BED ❑ Distance to ewrest: Well Foundation 1 Property Line 1 /n SEEPAGE PITS -1Depth;__- rR ' Size /:s Number SUMPS ❑ , Distance_to nearest-.'--"WeII Lj \. Foundation Property Line DISPOSAL PONDS Q'/I I hereby certify that I h6d'prepared this application.and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of`the San Joaquin Local Health District. I Home owner or licensetl agent's signature certifies the following lI 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 I 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 Calfforhia." i The applicant cal .for_all.-regpections-Complete drawing'on"remeise side: �r� Signed _ Title: �-��// 4R r Date: -Y/07z P,?7 FOR DEPARTMENT USE ONLY Z� Application Accepted byr Date 7 Area V i Pit or Grout Inspection y _ Date a. Final Inspection b 3 r`.?y �-'�Y'.5 ik. p Y Date . Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 I] Tracy 835-6385 s a Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEF INFO AMOUNT DUE AMOUNT REMITTED C K H RECEIVED BY DATE PERMIT'NO. EH 13-24(REVI i EH W26 f1� . _ 7- s-/,?- c�