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APPLICATION FOR PERMIT Y' SAV JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE;TON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Applteation is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described_ This application is made in compliance with San Joaquin County Ordinance No.5+19 for sewage or No. 18&2 for well/pump and the Rules and Regulations of the Sara Joaquin Local Health District. 1rsLC �'Yt Cit ] L�f Lot Size ) Job Address �..�._�.. -- :.------ — y_ =.,K��./1�. C.-71--_ PM Owner's Name __.�._. dtlress �� _ � Phony 't Coniractoi '" _ _, ddre'sl,: L__ "'J__L��r -�icetasr`Nv-tj } PhonE � TYPE OF WELL/PUMP: NEW WELL fJ WELL REPLACEMENT U DESTRUCTION 1 PUMP INSTALLATION D ` SYSTEM REPAIR U OTHER C, DISTANCE TO NEAREST: SEPTIC TANK SEWER LI S _..: DISPt75AL i L0;• � PROP:LINE��_ FOUNDATION _._ AGRICULT R ELL• OTHER WELL,. PITS/SUMPS ---ANTENDED USE TYPE OF WELL' PRO8'.EMAREA STRUCTION"SPECIFICATIONS"" i 11 C7 Industrial [�Op6li ottom C7 Mea teca Dia. of Well Excavation Dia.of Well Casing _._. U Domestic/Private G Gravel Pack U Tracy I Type of Casio ; i7 Public !-1 Other n Delta ; Depth of Grout Seal _ �� .Type of Grout i I Irn}7ation •_.,Approx. 04th-1•133 Eastem'� Surface Sail installed by Repair Work Done 13 Type of Pump _ H. _ _-.... !.__ State Work one a Well Destruction Cl Well Oiametar,�._ _. _ ,Sealing Material {top Depth ifiltcr Materiai.iBelnw 50') j I TYP£OF SEPTIC WORK: NEW INSTALLATION iiil FIrPAIR>ADOITION't a DESTRUCTION I (No septic system permitted if public:sewer is �/ �t available within 200 feet) installation will serve: Residence.._s! Commercial___ Othul+\A Number of living units: _ Number of bedrooms_S7. — Character of soil to a depth of 3 feet: � _Water tae depth _ SEPTIC TANK O Type/Mfg + _....... Capaeily_�.G.,.f table No, Compartments _ r PKG. TREATMENT PLT,t i �.. i Method oDisposal ' %. f r � t � _ Distance to nearest:t Well_y?_.�. Foundation .. Property Line_! I LEACHING LINE: r No. &Length of Imes Total length/istie. r�t FILTER EIEO LJ Distance to nearest: i Well L"JOL- Foundation ,�_QProperly fine jr _...... sr SEEPAGE PITS l Depth _. t Size Number SUMPS i 1 Distance to nearest: Well.. _ l. tFoundaiio _._ Property Line � DISPOSAL PONDS Lj l: 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 District. Horne owner or licensed agent's signature cattifies 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 becomesubject to workman's compensation laws of California.-Contractor's hiring or sub-contracting signature f certifies the,following:;I,terU#y ttapt.in,3tlgpNrtormsnca of the work for-wttich this•perrrwt.is issuad;A shallempioypililrsams sutrjact to•woricrnarrs-comrwririsa. tion laws of California." w The applicant 5pust call fu�r8gt4red 1 opections. Complete drawing on reverse side. ; q Signed X...../ ...� �� _ Title: ..., i��.✓`f r _ Data: FOR DEPARTMENT USE ONLY Appliation Accepted by v Data _ Area Pit nr Grout Inspection by _. Date_.._. Final Inspection by Date Additional Comments: .. i ❑ Stk 466-6781 0 Lodi 369.3621 0 Manteca 823-7104 0 Tracy 835.6385 Applicant- Return all copies to: Environmental Health Parmit/Services 1601 E. Hazelton Ave., P.O. Box 7009, Stk., CA 95701 l FEE AMOUNT DUE AMOU T REMITTED CK RECEIVED 8Y DATE PERMIT NO. INFO CASH i ry EM?4716