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APPLICATION FOR PERMIT SAN JOAQUIN�LOCAL HEALTH DISTRICT 1601 E. HAZLTON AVE. STOCKTON, CA -1 —T 41i ne (209)-466-6781 PERMIT EXPIRES'1'YEAR'FROM DATE ISSUED;' d" (6mplete 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 I made in compliance with San Joaquin County Ordinance No.549 for sewage,or,NoY1862 for well/pump and the Ryles and Regulations of the San Joaquin p,� ,Local Health District. - "k " V52 � �.;,. I) + .. q,. '�; Y i :�` �• �-~N:�''� r f�-�U ^f.T D-ted/ r Jab Address goo Z City' t Lot Size PM Owner's Name VA7&NA G Address ' .Z Z W �p� .671715 ione Contractor /QfT� XNQ Address 41,MO License No. Phone TYPE OF WELL/PUMP: i NEW WELL (,,WELL REPLACEMENT ❑y, tDESTRUff lON ❑ �.�,r 7'F'�.:! } ;.A3 'S., J�/af.✓7511:!1 ,.. PUMP INSTALLATION ❑ SYSTEM SEPAIR'�❑ OfiHER. �P Gpy��^V A6461 INSTANCE TO NEAREST: SEPTIC TANK !of SEWER LINES DISPOSAL FLD. PROP. LINE J k FOUNDATION-- — A'GRtCt1L`T-URE`NVEL'L��OTHER`WEL'L-7-: "`-`^PITS%SUMPS-1 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well ExcavationF or Dia. of Well Casrn9 XDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casin fi I Specifications r ❑ Public' Ot er 1-1DeltaDepth of Grout Seal 2d3 Type of Grout ❑ Irrigation pprox. Depth El Eastern Surface Seal Ltalled-by-- Repair Work Done ❑ TypTf Pump H.P. State Work Done r:. Well Destruction ❑. Well Diameter Sealing Material (top 50') I Depth Fille`�Material {Below 50'} 1 TYPE OF SEPTIC WORK- NEW INSTALLATION ❑ REPAIR/ADDITfON ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is `, 1 availhifi�'withi 200 feet.) Instal tion will serve: -Residence, Commercial— Other Number of living units: _ANumber of bedrooms Character of soil to a depth of 3 feet: } ' t 1 R I l Water table depth VEl ' C PKG. TREATMENT PLT. El Type/Mfg SEPTIC;TANK ! I =t Capacity No. Compartment's^*'+ 1 i t Method'of Disposal Distance to nearest: Well _ Foundation =Property Lirie } LEACHING LINE ❑ No. & Length of lines t #; ►I d "`p" w.. Tata( length/size .f FILTER BED ❑ .Distance to nearest: Well--&,—- Founda4i'"L 'Pro ' perry Line ' SEEPAGE PITS Elpepth Size # Number SUMPS ❑ Distance to-nearest: WeII ;--I 1!�'srJt _ ,.Foundation Property Line�-J t. DISPOSAL PENDS ❑ 1 I , 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�oaqg1 uin Local Health District: . 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 manner as to become subject to ,6b kman's compensation laws of California•"'Contractor's hiring or sub-contracting signature certifies the following:"!certify that_1riathe performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laves of California." t # 4' }Ft The applican11 us all for all eq 'red`inspections. Complete drawing on reverse side. Signed 1A Voltitle.... —-- r. g1�L friq�F1 S' 7�!i✓ @�C– s1.GCrsH ?,rvc. Date: 0trDpeTMENT USE ONLY Ap ication A epted by Date y teinal Inspection by41 Date _ r Additional Co ftnents:- LlStk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-6385 g�;' f �� Applicant- Return all cgpies to: vironme I alth P r iawg t/&ervi i E.HH on Ave., P.O. Bpx 2009, Stk.,,CA 952{11 FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY INFO 0,4F." DATE PERMIT"N0. f_ + EH 13.24(REV.1/s 5) [,� ;'•° X7,0 �,{y w*y, R ( •� { �� EH 14-26 /,�•� =}y .. +ti?.'. '!i - ;`O-. '/ 'W r /�.77�