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APPLICATION FOR PERMIT �I SAN JOARUIN.LOCAL.4ALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 'Telephone (209) 466-6781 11 In PERMIT EXPIRES71 YEAR FROM DATE. ISSUED -. 7 (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 Regulatiohs of the San Joaquin Local Health District. It yr.. r ^'r` it �. �",9 ,.a •*+" .. y� .r City s��i�� ize ... PM Job Address _.�Q�_._ [�%��--- lot .S' 7-�x i dla -� Owner's Name t�R. 'ti�%�s�—' —Address - . k; Contractor tC Address Q. 6� �,ay i�^�--License No. 2,-C.34 Ph TYPE OF WELL/PUMP: NEW WELL J WELL REP.LAC£MENT.l I DESTRUCTION F-1 11 u,, . ytntl• S STEM RPA1Fi �"'"'-OTHER 0_.• �....,-PUMP-INS7AL-LATION E DISTANCE TO NEAREST: SEPTIC TANK —_ SEWER LINES — DISPOSAL FLD. - PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL. PITS/SUMPS - INTENDED USE 'TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LAndustrial .I Open Bottom Ll Manteca Dia. of Well Excavation Dia. of WellCasing �+ specifications 1 C'-Domestic/Private ❑ Gravel,Pack ❑ Tracy Type of Casing P Public IJ Other , �0 . i-1 Delta Depth of Grout Seal ❑ Irrigation �Approx. Depth M Eastern Repair Work Done L3 Type of Pump ' H. P. Well Destruction -1 Well Diameter Sealing Material atop 501- r ` f Filler Material i Below " ``= - } Depth Ill § TYPE OF SEPTIC WORK: ;NEW INSTALLATION 'J REPAIR'/ ADDITION ■ PESTRUCTION 9 (No_Aeptic system permitted if public sewer is ilable within 200 feet.) I Installation will serve: Residence !� Commercial _ , Other_— } SSS I i Number of Irving units: _A_( umber of.bedrooms = - IF f I .`.:z.._ f Water table depth Character of soil to a depth of 3 -feet:--_ iQt3-- ` """ t'TE -r Capaci; 120 0 No. CompartmentsJ'� SEPTIC TANK Bl Type/Mfg Method of Disposal G. TREATMENT PLT. G ` ` '- r ri Oistance,:fo nearest: Well •�r..1fL Foundation _ !X -Property Line la j - �Y Type of Grout Seal installed -by r Sate Work Done } LEACHING LINE O t No. & Length of lines __, �ls+� E" - Total length/size-� DATE FILTER BED., 1 J� Distance to nearest: Well Foundation Property Line II SEEPAGE PITS O Depth _:. Size j Numberi Lin0""""K SUMPS It Distance to nearest: Well p0 Foundation �Q. Pro , DISPOSAL PONQS I hereby certify that I ha4,`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.. +- I %., , II i I Horne owner or licensed agent's signature certifies the following: "I certify that in the performance of the work'for which this perm t is issued, I shall not employ any person in such manner as to become subject to_workman's compensation.laws.of_Californis." Contractdr..s hiring or sub�ontractrng signature colifies rhe following: "I certify that in the�periormarice of the work for,which this permit is issued, I shall employ persons subject to workman's compensa- �.., a ti j tion laws of California." 1 The applicant must call for all required inspections. Complete drawing on reverse side. Signed •-- - .Title: Date: ti FOR DEPARTMENTTJSE ONLY Date !! / !` Area �. _ -_ Application Accepted by I r Date yc� Final Inspection by _ Date Pit or Grout Inspection by -- •AdAirinnnl Comments: two� 67$1 [ rL 3693621,,..,=fel•Manteca -823-7104-----f.--i•-Tracy--•M-6386-�~-w----'� Return all copies to: Environmental Health Permit/Services,11601,E. Hazelton Ave., P.O, Box 2009, Stk., CA 35201 r EH 19.24 4REV, ` n `•,1 EH 1426 FEEAMOUNT DUE AMOUNT REMITTED CASH ' . RECEIVED BY DATE PERMIT N0. INFO _ ..