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I APPLICATION FOR PERMIT ! SAN JOAQUIN LOCAL--HEALTH DISTRICT �I 1601 E. HAZE.T ON AVE., STOCKTON, CA II Telephone (209) 466-6781 I, PERMIT EXPIRES VYEAR FROM DATE ISSUED I! (Complete in Triplicate) w 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 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 fff Local Health District. q�c'K Job Address pa Cit�r 4510 d-3 of Size A t+'ePM II _ .I;. 3 -0 Owner's Name _-C►rtE Y I Vl frf LCk Address 1 1-0 YC A Phone Gy 3 4 li gL52a� Sa t�� Phone !`227 'Jr.l� Contractor Address . ` S d U icense No. TYPE OF WELLIPUMP: II NEW WELL ❑ WELL REPLACEMENT [Y DESTRUCTION PUMP INSTALLATION 5K SYSTEM REPAIR ❑ OTHER ❑ ®� DISTANCEJO NEAREST: SfPTIC TANK _1sL5Z — SEWER LINES 150 DISPOSAL FLD. PROP. LINE FOUNDATION O AGRICULTURE WELL OTHER WELL PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS + ❑ Industrial - El Open Bottom Q Manteca Dia. of Well Excavation_� Dia. of Well Casing [1VGravel Pack ❑ Tracy Type of Casing ea y C" Specifications VDomesticlPrivater�^..�.N't$yl� Ll _ ('l Public Other it Delta Depth of Grout Seal tt�� T pe of Grout I I Irrigation 11. -Approx. De th I 1 Eastern Surface Seal Installed by C W �Yt`E��f k Repair Work Done ❑ Type of Pump H.P.o ?. State Work Done Rel'-SAIJ 1'1 lie tAlG r Well Destruction [Y' Well Diameter rSealing Material (top 501 Depth 80' Filler Material ;Below,50 TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION 1 I DESTRUCTION I I (No sbpticle system m permitted if public sewer is I � I l 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 jSEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation Property Line l LEACHING LINE ❑ �:No. & Length of lines Total length/size FILTER HED ❑ I Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS I l.jl,Depth Size _ Number ' SUMPS L,IIII 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 rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "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 to workman's compensation laws of California."Contractor's hiring or subcontracting signatur certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa tion laws of California." �I f The applicant must call for all required inspections. Complete drawing on reverse side. Signed X I Title: _ — w _� Date: a I FOR DEPARTMENT USE ONLY Application Accept y I' _ Date Area Pit or Grout Inspection by bate 4 w - Final Inspection by Date�...— Additional Comments: O 171Stk 466-6181 ElLodi 36.9-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 } Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I II FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED illPATE PERMIT'NO. INFOt��y r Cary_�'"l. /Jt°�i�i//�•i�� +.EH13-241pEV.tin51 1 1 14� 14' V p–. q k0eP /�� EH 1I 29 rye.` .t C r'- ill . C(c+fl VV