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v APPLlGATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED JAN 0 3 1950 (Complete in Triplicate) p�SAN JO��-11AQUIN COUNTY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or inst@�'{4yUW� )��n A"Spplication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump an }1I �oW(DWISM Joaquin Local Health District- A ,v Job Address 7 03 PACA F-J iL 7� Citys ' Lot Size IZO X 10 PM 21ISAI• CAL F0R4'WAL&Lot-- Owner's Name OCAr�� Address St/1i,C (05+ CQQ� Phone 15 945 X76 7 Contractor py}"p►SO CO&W T: Address 62,20 5TZg DA1C1"b License No. 2 59S Z C7 Phon Z -55 TYPE OF WELL/PUMP: NEW WELL-0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE T4 ST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P LINE TION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL BLEM AREA CONSTRUCTION SP TIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of xcavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy y Casing Specifications (I Public Cl Other ra Depth of Gro I Type of Grout I I Irrigation -_ -Appro pth l I Eastern Surface Seat installed b Repair Work Done ❑ of Pump H.P. State Wor _ Well Destruction Well Diameter Sealing Material (top 501 sr Depth Filler Material (Below 501 4" t TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I.I DESTRUCTION (No septic-system permitted if public sewer'is ' available'within 200 feet.) i installation will serve: Residence,,.._ Commercial X. Other . f�\O i r /U� '�" Number of living units: �' Number of bedrooms ilY c} N ! *� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK N" Type/Mfgu 14 tS Capacity No. Compartments _ PKG. TREATMENT PLT. ❑ Method of Disposal ► 5 �- Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance t6 nearest: Well Foundation Property Line SEEPAGE PITS I:I Depth i' Size Number 1 SUMPS ❑ Distance to-nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, and i rules and regulations of the San Joaquin Local Health Di1trict. + . . • . Home owner or licensed agent's signature certifies the following:g g g: "I certify that in the performance of the work for which,this permit is issued, I shah 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 o California." The applica t call for all quired i tions. Complete drawing on reverse side. , Sig Title: FOR DEPARTMENT USE ONLY �] Application cepted b Date ` 1'" 0 Area Y Pk or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca823-7104" ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Av>3., P.O:'.Box 2009, Stk., CA 95201 - -- e FEE AMOUNT DUE AMOUNT REMITTED RECEIVED 6Y DATE PERMIT NO. E GAMOUNT DUE ..E"13-24(REv,1/n 51 y EH 14-2e t d l 1 '"y '/ O �0 '� - I � i