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4_ t s APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA } Telephone 12091 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 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. i Job Address City CsSCn,&A) Lot Size C:n 19TE4S PM I Owner's Name ILI I � RIO_ - - Address Phone LA I;antrac4o I Address License No. Phone 7' TYPE OF WELL/PUMP: i` NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 121� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK e-- SEWER LINES DISPOSAL FLD PROP. LINE FOUNDATIONAGRICULTURE WELL THER WELLPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS p S N ❑ Industrial ❑'G pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing LO i pomestic/Private [Gravel Pack ❑ Tracy Type of Casing Specifications ['I Public ❑ ``Other la Delta Depth of Grout Seal Type of Grout.. I I Irrigation - -'�F:Approx...Deth I. I Eastern.._„_._..�SYace_Seal-tnstaNed_by, __r ' Repair Work Done . Type of Pump SQ H.P. _ State Work Done i Well Destruction LIWell Diameter Sealing Material (top 501 ' Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I.] REPAIR/ADDITION Ll DESTRUCTION l I 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 dept Fil of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation - Property Line _ .B LEACHING LINE ❑ II No- & Length of lines Total length/size FILTER BED i ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I depth F Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i I hereby certify that I have pfepared 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 Di1trict. 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 mAnnef 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 CalifoLwa�. The applican .mu calf for all required ins tions. ate dr wing feversa side. IIS Signed rt ��( _.__�/�/ Date: TMENT USE ONLY Are Application Accepted by Date ' r 011 Pit or Grout Inspection by Date 11 L Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 C7 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 —FEE !-- - - " ••�^ INFO �AM�`UNjT DUE=rte'";" , AMOUNT REMITTED— �CAUS(H� '� RECEIVED l3Y'�` t�D"A]TE�� TpPERMIT�yNO'"! kf EH 13.24EREV.rin51 �! ! OS•d0 i IDS',CI t] 1-1 '+ ? 1�_�1� /��A0 pZ r i EH 14-26 ti