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Iwo 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 herein described.This application is made atcompliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/Dump and /the Rules and Regulations of the San Joaquin in Local Health District. 1 5_rDC yG 1-0 f ilq!e Ho�Acv cT (C1j�yT'WJ_01> � Woe Wr.Eity. Lot6;�e 3.46 Qtl2. PM Job Address 713 69(077 3- df Cp a SA Addres�200 SH!TN S)• NouS>Dn� TX Phon Owner's Name XofC 57IS 685-661 �✓ 6�6 ai-90#14) CONCOK� License No $L390 Pnor4 1/.r:. uwr.lj. (,LIrGc DQ/LGl rnttBress Contract dr--��— ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ N�W / •, ,. ) TYPE OF WELL/PUMP: SYSTEM REPAIR 0 OTHER �— �— PUMP INSTALLATION 0 ��, pflOP. LINE 10 SEWER LINES 570 Ft' DISPOSAL FLO. DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WEL�E Fl GPITS/SUMPS FOUNDATION / TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r n Dia. of Well Casing L) INTENDED SE c��fj,Zro ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation G 91 Specifications Gravel Pack ❑ Tracy Type of Casing /Cry['N 1-t QS i=N 0 Domesticl Private ��// Depth of Grout Seal 20 Type of Grout`_ 0 Public n Other ;<0elta Q1 LL Surface Seal installed I I It, anon —Approx. Depth l I Eastern State Work Done ey ' z K'3 K r CO f2+ N o[ Pump H.P. epalr Work Done TVP" Sealing Material (top 501 Well Destruction 0 Well Diameter Filler Material lBelow 50'1 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION I I afivailabllelw thin 200 feet.s stem �ed if public sewer Is Installation will serve: Residence Commercial_ Other Number of living units: __ Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK C] Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ Property Line Distance to nearest: Well Foundation P Y LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 11 Depth Size Number SEEPAGE PITS SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health District. issued,work for Home owner person in such mannerastore certifies the become subject Ito wlorkman'srtify comthat in pensation lhe awsormance of California." Contractor'slhir hiring or sub-contractnngisignature employ any pe 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 apDlican #t calor all required inspections. Complete d,awing an reverse side. I$ 1 9 } 0,UG1 erf?4 4lC 0/��itle: CTE 0Lc�G %Sr Date: Signed �� /� FOR DEPARTMENT USE ONLY 7 wz'' Date 7 q0 Area Application Accepted by t J Date /f7 / Final Inspection by Date Pit it Grout Inspection b��YX . %i k J p / /- / Zoe �EG'e/�'-„t.C. K . R/T fes. �CyC�'l, d c.cK Al Additional Comments: ❑ S[k 466-6781 ❑ Lodi 369-3621 ❑ Mente 823-7104 O Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 , K RECEIVED By DATE PERMIT NO. I FEE AMOUNT DUE AMOUNT REMITTED _ INFO . EM I1N IRfN+rih si 6 5I3tgc o o4Z