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APPLICATION FOR PERMT SAN JOAQLiN LOCAL H74LTH DiSTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. G Telephone (209) 466-5781" DATE ISSUED 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. Ihis application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulart�ioons of the San Joaquin Local Health District. Job Address�7(e77 W/g7CX198 ._ Subdivision Name j G� Owner's NamerJ�L{� Lv�c��TT/ 01 Address Phone 781-H940 Contractor's Name License No. Phone ()) TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ `,PUMP INSTALLATION ❑f ,SYSTEM REPAIR' � � � OTHER (❑ DISTANCE. TO NEO ST: SEPTIC TANK '-'SEWER L''"INES f ./ " __;--DISPOSAL FLO. PROP, LINE FOUNDATION' AGRICULTURE WELL - OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑) Domestic%Private ❑ Gravel Pack,. Tracy - Dia. of Well Casing a, J ❑ Public ❑ Other ❑ Delta r Type of Casing`, 1 Fj Irrigation Approx. ❑ Eastern Specifications ❑Cathodic Protection Depth Depth of GroutSeal Geophysical Type of Grout,./ ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work.,.�Don�e Well 6estructidn ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') CIQ TYPE OF SEPT ❑IC -,WORK: 'NEW REPAIR/ADDITION (No septic tank or .seepage pit permitted if public sewer-i5 f , r► s•� available within 200 feet.) _ Installation will serve Residence Commercial Other Number of living units: _� Number of bedrooms W�, Lot size 'Ana-'s-5 f �, / Cj�� Water Character of soil to a depth of 3.1=eet':.% table depth_ - SEPTIC TANK ❑ Type/Mfg +" Capacity No. Compartments.,____—., PKG. TREATMENT PLT. ❑ Type/Mfg ° Capacity �f "* ,.Method-of D!-Sposal •• SEWAGE SYSTEM Distance-to nearest:_Well - Foundation h-.� Prbpert�:tie —_1' N (- DESTRUCTION Q P I LEACHING LINE �, No. & Length of lines /o _-?o,al-"length/size FILTER BED Distance to nearest: Wnll /(WFoundation -,1(D '? Property Line SEEPAGE PITS { Depth --C ---- %SizeAf Number �i S SUMPS Distance to nearest: Well , AS; Foundation Property Line, DISPOSAL PONDS 9.. ��` i # . I hereby certify that I have prepared this application and that the work will be done in-ac.cordarcewith San Joaquin county' ordinances, state-laws, an'd rules and regulations of the San Joaquin Local HealthDistrict'_s' Home J n the performanceof the work for which this permit is issue I shall' not employ any`,person in such manner as to become subjects-to workman compensation laws of California." ! Contractor's h' ing or sub-contracting ,gnatu"re'certifies the following- certify that in the performance of the work for which this permit i i sued, I sh 11 emplo ersons\subject to workman,*s compensation..'laws of,California." ?-- r The appli t s 11 f ,e11 r u red in coons. Comple dr �re �esSigned Title: Date:i i'ft~� 4 v Application Accepted by Area 5tk 466-67$1 i Additional Comments:' �` c ^^ r---, Y ❑ Lodi 364-3621 Pit or Grout"Inspection by'- Date �y �❑ Manteca 823-7104 -1 Final Inspection by ' 1 Date k".? �� I!". Tracy $35-6385 I .._..` Applicant - Return-all copies to:—Inv tronmental'Hea1th Perm it/5ervic es 1601E. Hazelto�veP,,O. Box 2009, Stk., CA 95201 4 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 10/62 sao. 14-26 c f