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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 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 Ryles and Regulations of the San Joaquin Local Health District. f Job Address 1.30+%�l�w ,A): -,Z.QC&7-rA/,-- QCity 4.0 �I __ Lot Size I�Z �� PM91 Owner's Name -DOA) *ZISE Address l ' Phone Contractor_-Jt�'_L",p Ind&J> Address + AAJ icense No.A��14 Phone 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r �_ _ .,_._P_UMP_INS--TALLAT.ION_.❑ SYSTEM,.REPAIR-O--------OTHER..M -.—II DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ab ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing1 D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout' ❑ Irrigation-._ _.,.,,",,,_Approx. Depih O.—Eastern— Surface Seal Installed by ` Repair Work Done ❑ Type of Pump H.P1 T�State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth "" —Fille-r Material (Below 50'1) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTIONJO (Nonseptic system'permitted if public'sewer is ✓ available within 200 feet.) t t,r•. Installation will serve: Residence� Commercial Other Number of living units: I Number of bedrooms_2- .r Character of soil to a dept of 3 feet: C,L A ------`"T'-""' - Water table depth SEPTIC TANK Capacity. No. Compartments PKG. TREATMENT PLT. ❑ { Method of'Disposal Distance to nearest: Well Foundation' Property Line z LEACHING LINE No. & Length of li esklio Total lerigth/size FILTER BED ❑ Distance to nearesf: Well Foundation f Property Line_ ,-SEEPAGE.PiTS'Ercl �� x ,r v•Depth•;- -size -L�� .�.� - - '�j � �- Number D SUMPS El-1`Distance to nearest: Well J00 Foundation Property Line 30 DISPOSAL-PONDS Fl, •.-.TT=--* - Tom. 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�bnd-regulations-of-the San.Joaquin'Local Health-Disirict'.-(7 I Home owner or licensed agent's signature certifies the following:-"I"cdRiq that in the perf&ina'nce of Lhewor0for which this permit is issued, I shall not emplciY4 ,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 this permit is issued,I shall employ,persons subject to workman's compensa- tion laws of California_,. The applicant:must call for all required in"' cti s. Complete drawing.on reverse side. Ir Signed X T, Ute+ TRW Date: - / ,zJ r FOR DEPARTMENT USE ONLY Application Accepted by Date -�`` ? Area O it r Grout InspectionqY Date� Final Inspection by ) � Additional Comments: ! ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 __Haz❑ Tracy_835-ON Applicant=RiFL rn all copies to: Envuo�' nmental Health Permit/Services 1601 E- elton Ave., P.O. Box 2009, Stk., CA 95201FEE ' INFO AMOUNT DUE AMOUNT REMITTED CASH CK I RECEIVED BY J DATE PERMIT'NO. EH 13-24+ EH 1426+RE-V.f/s5) ` c.� _ /�9/ Sr5 s-H