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APPLICATION FOR PERMIT SAN JOAQUIN LOCAI 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 appFcation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pl mp and the Rules and Reguktions of tfr San Joaquin Local Health Dlsiric t. Jeb Address >!� 1_LF CityLot Size PM Owner's Name t/( �.//(-� . _�. Address 1�-�V• Phone / l r / , Contract ,:Lr:J_ ,y/e'l, i,�_ ,_ Address�XfCX �P t>2 z License No. .,1 r�4 Phony TYPE_OF WELL;PUMP: NEW WELL 11 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 7 SYSTEM REPAIR ❑ OTHER ❑ 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 7 Manteca Dia. of Well Excavation Dia. of Well Casing _ Domestic/Private Gravel Pack Tracy Type of Casing__ Specifications Public Other Delta Depth of Grout Seal Type of Grout Irrigation _._ Approx. Depth Eastern Surface Seal Installed by O Repair Work Done Type of Pump H.P. --_._ - State Work Done Well Destruction Well Diameter Sealing Matennl stop 501 Depth _ ___ _ Filler Material 18elow 501 - W TYPE OF SEPTIC WORK: NEW INSTALLATION i--' REPAIR/ADDITION L DESTRUCTION U INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial- Other � `�"'' Number of living unite: . _. NumberA/y_edrooms Character of soil to a depth of 3 feet: _/rr' - tt;`1 - -Water table depth r SEPTIC TANK Type IMfg L^24,-_L^24,-_ ��L«'A Capacity._�T C - No. Compartments 01 PKG. TREATMENT PLT. G / , Method of Dppoaal __ 6. Distance to nearest: Well J._ Foundation A- -___. Property Line__5_ LEACHING LINE t' No. & Length of lines _J_-�/� Total length/size FILTER BED Distance to nearest: Well S[ Foundation le' Property Line S _ SEEPAGE PITS r Depth ____Size ys Number SUMPS Dist,e to nearest: Well�L`L_- Foundation le' ---- Property Line S DISPOSAL PONDS I hereby certify that I have prepan•.I 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. 1.-me 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 sub-contracting signature certifies the following:"I cenifv that'n the porf.:rmance of the work for which this permit is issued,I shall employ persons subject to workman's compensa tion laws of California." The applicant must cal!for all required inspections, Complete drawing on reverse side. I _ Date: /1,r.2(,t, j- c`c. 1< ` . Signed X______ _ Title: ___. FOR DEPARTMENT USE ONLY Application Accepted by -� ____ Date 6_L �+_ Area �yJ a`ry`l/"c Vis= -}� � r Grout Inspection by -' �!/ - Date..__�/-_�-.. Final Inspection by.` `-/1-�Z- �,- Date_ �b Additional Comments, __ -_ -- - - - - - -- ---- ----- Stk 466.6781 Lod, 359 3621 Man.cca 823.7104 ❑Tracy 8356385 Applicant Return all copies to F+voronmental Health Permit/Services 1601 E. HazeRon Ave.. P.O. Box 2009, Stk., CA 95201 FEE AMO'^" ':SUE AMOUNT REMITTED GASH RECEIVED By DATE PERMIT NO INFO ApnIiCANT fir tUnN Ail fOVlfS to rNVIr10NM[NTAL NtAITH P[eMIT9ENVICeS 1001! HALtLIUM Art IV.OY- KW MW �ws •.v..w�..,..w.... -- +;v.n +...a.+r"s',...