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O APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Appliceiionlis 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 m Local Health District.Z't Job A ld'r �q�lo lie Q�A/ City oc Lot Size //OX ./�V PM Owr's N D _��/ = Address sL 6 C � A/ Phone f2/� � �3 - neame kJ Contractor -__- License No, __Phone I Address - TYPE OF WELL/PUMP: NEW WELL ❑ W LL REPLACEMENT E DESTRUCTION 71 PUMP-INSTALLATION,L� Y SYSTEM, REPAIR,,::__—OTHER J� f DISTANCE TO NEAREST: SEPTIC TANK _ SEWER-LINES _ DISPOSAL FLD. u PROP. LINE - r-FOUNDATION "-'AGRICULTURE WELL OTHER WELL'+ - PITS/(SUMP,S INTENDED USE l' TYPE OF WELL, PROBLEM AREA--CONST.RUC=N SPECIFICATIONS— - O Industrial 1-C Open Botiom C Manteca Dia.of Well Excavation Dia,�of Weil Casing 1 Domestic/Private t Gravel Pack C Tracy Type of Casino Specifications Y (I L Public- _ :1 Other = k G Delta Depth of Grout Seal _ Type of Grout v, C, Irrigation `s tr `�_-Approxi'Depth O Eastern Surface Seal installed by tT I Repair Work Done ❑ Type of PumpJ___ H.P; _ State Work Done Well Destruction Z�t'Weil Diameter I Sealing Material stop 50') ll < + Depth ; Filler Material (Below 50') TYPE.OF SEPTIC WORK: NEW INSTALLATION C REPAIR/ADDITION 25'-_DESTRUCTION C (No septic system permitted if public sewer is `\ availeble within 200 feet.) t JInstallation will serve: Residence Commercial..— Other Number of living units: f Number of bedrooms __Z' Character of soil to a depth of 3 feet: ` r I c�n _. Water table depth0 SEPTIC TANK s ,OR'-Type/Mfg C yc �P I Capacity�t�0 _— No. Compartments L i PKG- TREATMENT PLT'❑ Method of Disposal Distance to nearest: Well loo Foundation Property Line O LEACHING LINE �O No. & Length of lines Notal lengthsize Rt+E+k-8Srr Distance to nearest: Well %OD Foundation Prop erty Line >, SEEPAGE PITS J Depth ___Size ��L-�d Number J ____ SUMPS Distance to nearest: I Well /?�O r Foundation �- Property Line� i ._ _1 4• DISPOSAL PONDS 11 J ""-' 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 4 1,,' rules and( of the San Joaq iln Local Health District. + Z- Home oydner 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 t employ aAy person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature i 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 applicant m t call for all a aired inspections. Complete drawing on reverse side- I S 4t 2'+�� _ Date: Signed X` -.._. Title: J FOR DEPARTMENT USE ONLY Application Accepted by Date "T Area `' Pit or Grout Inspection by ate rI Final Inspecti by Dat AtComments: J _ . �' A n j` "Os tk 466-6761 ❑ Lodi 369.3821 Manteca 673-7104 ❑ Tracy 5-6386 Appllcant- Return all copies to: Environmental Health Pern-Al Services 1801 E. Hazelton Ave., P.O.Box 2009, Stk., CA 95201 I I J '^ FEE _ _ -- INFO- -AMOUNT DUE - -AMOUNT REMITTED RECEIVED BY DATE "PERMIT'NO, j a EH 13.24 TREY,1/6b) - ��''•'— �"`�( S�SS .L EH 14-26