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APPLICATION_FOR PERMIT t SAN JOAQUIN LO_ CALF HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-Ml PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �'f �'° ` ` ^ .•'1s,: (Complete in Triplicate) a GAC""(- j 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 Ryles and Regulations of the San Joaquin Local Health District, -91 ' - ~` Job Address City Lot Size ' _ PM Owner's Name /T� �L t� -Address Al rC! 0 Phone Contractor • Address © _Iv�wf`�S`d��License No. Phone TYPE OF WELL/PUMP: NEW WELL,❑ t WELL REPLACEMENT ❑ DESTRUCTION O _PUMP INSTALLATION,. ` SYSTEM REPAIR DOTHER-0 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. V PROP}LINE \r>� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I \ .„WTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j Industrial 7 Open Bottom ❑ Manteca Dia. of Well Excavation Die. of Well Casing •k;i� Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing____-r-+ �� Specifications -� 1 'D Public ❑ Other ❑ Delta Depth of Grout Seal / Type of Grouty D irrigation _--Approx. Depth ❑ Eastern Surface Seal Installed by--- Repair y__Repair Work Done ❑ Type of Pump H.P._ 77S,7' State Work Done t. Well Destruction ] Well Diameter !j Sealing Material atop 50'1 f Depth l f Filler Material iBelow 50'1 TYP€OF SEPTIC WORK: NEW INSTALLATION ❑ REP IR/ADDITION DESIRU,CTION�LI�(No septic system permitted if public sewer is 1 avada6ie within 200 feet.lj } instal attion'will+serve: Residence Commercial—. Other j + f t Number bf�iiv'ing units.-4— Number oftedt0a � `Character of soil to'a'1depth of 3 feet:I _ _ _ _Water table de{jth► r ? 71raJ,:SEPTdC TAfVK, � � TYpe/Mfg`. T Capacity fes/ No.. Compartments K(i- TREATMENT PLT. ❑1 f+ t-' / Method of Disposal __...._ 1 :. t sfance,o nearest: Well 1©o Foundation �� Property Line LEACHING LINE No. &Length of,lines _�_ v ' �h• Total length/size_— C&AIl �;. FILTER BED L L�`Distance.'to nearest: Wall Foundation Property line ld_.d '� / Js ,SEEPAGE.ITS`w"" C�Depth �, Size / SUMPS 'z"1n::C.:-.JDiptance`.to nearest: Well FoaA,Lon % �'4) Property Line "_J DISPOSAL PONDS r r I hereby certify that I have prepared this_applic,,ation'a�dtka tthe w&k` riWlI-be' one-in wi accordance' th-Sen Joaquin`courtty ordfnanCgs; to laws, and rules and regdlations of the San Joaquin Local,Health District- Homeowner or licensed agent's signature cel-tifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not r =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"follo :,'I certify that in the performance'of the work for which this permit is issued,4 shall employ persons subject to workman's compensa- tion laws ofe- rfom The appliC S must II all required lnectians. Complete drawing on r e side. - 7 Signed - -. ' Title: Date: 41��. � ✓`J-� �"'"f i USE ONLY - - Application Aycepted by �DE;ARTMENTDate ZZ Area O or Groui7r spection by �f Dat Final Inspection by + Date Additional Comments: "-:E 171Stk 466-6781 ❑,,L`odl 369-3621 '` C Manteca 823-7104 O Tracy 83543385 O; E f 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, S&., CA 95201 l r ' FEE AMOUNT DUE I t AMOUNT REMITTED CK* RECEIVED_BY, DA PERMIT''NO.� y INFO. - - .�- �L; _ - _ �.G�ASH - pp EH 7374 IREV.11857 , ": D'�'f,"r�-'M `�Y A �,�` �` - �D 7 pc- 6-S EH 1476 �. 3 �:�. p2!-PJ