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;.� APPLICATION FOR PERMIT �► SAN JOAQUIN LOCAL HEALTH DISTRICT pgyM�Nr PAYMENT PY C(O 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVEID Telephone (209) 466-6781 NOV 2 7 1959 PERMIT EXPIRES 1YEAR FROM DATE ISSUEDSAN JOAQUIN COUNTY rtJdLIC (Complete in Triplicate) ENVIRON ENt ALTH HEALTH DTIV Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. fn l Alication 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 Local Health District. Job Address _107 AAWft Sia L City 40) Lot Size �/70 / PM Owner's Name h� uo%.�Mt M�CF�>Gf-� Address I1), 0 �R2)D�>` CA, ! l Phone xz°Al` sTr X / 1<9/6 1 Q Contractor �✓ XV' ddresswooDjA�luD r'i4, �� License No.alS,�}33 a b Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ / PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER K 5611- DISTANCE 610DISTANCE 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 O Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing O Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications M Public P Other W(IJ& n Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diamet r Sealing Material (top 50') Depth 'a!/ Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 Di?;trict. 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 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 of California." The appliant ust ca cll for all required inspections. Complete drawing on reverse side. SEE �fflCif. N'� Signed X Title: arok SE Date: 1/aa11?q FO DEPARTMENT USE ONLY /► Application Accepted bll T"'�-""' Date Area �o�� Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 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 CK IEEE AMOUNT /DUE AMOUNT REMITTED CASH RECEIVED BY ``�( DATE PERMIT NO. ♦ EH 13-24 IREV.tins! � (/�� 1 EH 14-26 ��