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� f APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT p A 1601 E. HRZELTON AVE., STOCKTON, CA PERMIT N0. -104V ' Telephone (209) 466-6781., 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. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San.Joaquin:Local Health District. Y v Job AddressSubdivision Name l Address q�7 "[ Phone t}�,i.� H-� l j Owner's Name �.Cr�t�. Contractor's Name �i�L�;1i1Q�� License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT ❑ DESTRUCTION ❑ � 'PUMP--INST-ALLATION-❑- — SYSTEM REPAIR ❑ OTHER- E-��.. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FUUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' INTENDED USE TYPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !] Industrial ❑ Open.Bottom ❑Manteca Dia. of Well Excavation F [j Domestic/Private ❑Gravel..Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other Delta Type of Casing t�- V Irrigation Approx. [] Eastern Specifications i Cathodic Protection Depth ❑ Depth of Grout Seal �]Geophysical Type of Grout ❑Other a Surface Seal Installed by j Repair Work Done Type of Pump' H.P. State Work Done Well Destruction ❑ Well Diameter f Sealing Material (top 50') Depth Filler Material (Below 50') } _ TYPE/OF SEPTIC WORK: NEW INSTALLATION'.L— REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of living units: " Number of bedrooms Lot size !� •�C /sv 1 k Character of soil to a depth of 3 feet: Water table depth (Q Q SEPT IC. TANK Type/Mfg - a aci y - i� �- No. Compartments �- ; PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal E SEWAGE SYSTEM ❑ Distance to:nearest: Well 4g:b Foundation I(j - Property Line DESTRUCTION �^• LEACHING LINE ❑ No. & Length of lines r—Total-Iength/si•ze }. .� '?,FILTER 'BED-. F-1Distance to nearest: Well Foundation Property Line SEEPAGE PITS- .[ } Depth .Size Number SUMPS ❑,, Distance,.to nea"rest: Well Foundation fir %Property.-L'ine .� *' ~• _DISPOSAL PONDS ❑ ` ' �'" '�Y-� ' `Ifhereby certify that I have prepared-this application and that the work wil hbe done in accordance with San Joaquin county ordinances.,,•sta.te,laws,rand_rules-•andaregulations of the San Joaquin Local Health District. - Home owner or licensed agent's,s,gnature certifies the following: "I certify that in the performance of the-work for which this permit is issued, I shall not em ploy any person in such manner as to become subject to workman compehsationflaws of California." Contractor's iring or sub4contracting-signature certifies the-following: "I -certi-fy that in the performance oT the work for which this permit issued,`I shall emplo perso subject to workman's compensation laws of California" _ .i-'- The appli st call f all re it d spect ons. Compl to d in on reverse side. y -*r,- r. Title: Date: Signed X l F T F ONLY cAn ❑ "°' Area Stk 466-6781 Application Accepted b '`gyp=4dditional CommentP ! [] Lodi 369-3621 Dat �o ❑ Manteca 823-7104 ;P -t`,or Grout Inspection ,e Final Inspection by Date. 141 ❑ Tracy /835=6.385 Applicant - Return all copies to: . En iron tal Heal#'h Permit/Services 160 E. zelton ve., P.O. Bax 2009, Stk.; CSA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECF0ED BY DATE PERMIT NO. -- Al p -- _ _ FSao • ��EH 1�3-24 �REV�10%$2 " 14-26 p