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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT + 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate)permit to construct applicationed.This is lor install the work herein Application is hereby made to the San Joaquin LocalHealth nce No.District for sewage or No. 1862 for well/Pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Local Health District. c city GIS Lot Size PM .�+�.. Job Address c 9 yac�o 3 ellS. m�?I/� S Q Phone `�!AN 2 1 s IAddrre$ l'1f5� Owner`s Name F!� �y,`r(11t71+ yy � �� .` Address -iMJ/w! ")4 �'cense No. Phone Contractor DESTRUCTION ❑ f ,NEW WELL ❑, .t WELL RA EMENT ❑ ` OTHER`� Sal d 13 02l NGS TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ t PUMP INSTALLATION 13 FLD. PROP. LINE _.1 DISTANCE 70 NEAREST: SEPSEWER LINES- 'EIC TANK �� AGRICULTURE WELL • OTHER WELL pITS/SUMPS FOUNDATION ` e INTENDED USE TYPE OF WELL x PROBLEM AREA CONSTRUCTION SPECIFICATIION` Dia. of 4WExcavation ❑ Industrial ❑ Open'Bottom [D Manteca Specifications Cl Domestic7Private f5 'D Gravel Pack. ❑ Tracy of Grout 9 Gewevr � ❑ Other, � Installed by ❑ Delta l IDepth of Grout Seal C 3O Fe�t Type oh E3Public Surface Seansta ❑ Irrigation � �4pprox. Deptfi ❑ Eastern State Work Done HP _ I Pump H.P. Repair Work Done ❑ Type of P Well Destruction ❑ Well Diameter �— Sealing Material (top 50'1 Depth 1 t Filler Material (Below 501 ( available within 200 feet.) f E OF SEPTIC WORK: NEW INSTALLATION ❑ ;REPAIRIADDITION ❑ DESTRUCTION ❑ (No septic system permitted if pu sewer is r Installatio ill serve: Residence Commercial_ Other L. S Number of living its: Number of bedrooms Water table depth Character of soil to aof 3 feet: No. Compartments ❑ Ty fg Capacity ,.- . SEPTIC TANK "..," Method of Disposal PKG. TREATMENT PLT. ❑ oundation Property Line Distance to nearest: ell k I � Total length/size LEACHING LINE ❑ No. & Length of lines Property Line FILTER BED ❑ Distance to n t: Well Found/ l 1 Size Number SEEPAGE PITS epth 3. Property Li i •foundation SUMPS ❑' Distance to nearest: Well DI AL PONDS k " ❑ i.r . . 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 f rules and regulations of the San Joaquin Local Health District. that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the ct to I 's tifyco nsation laws of California."Contractor's hiring or sub-contracting signature i employ any person in such manner in to become subject c workman's aompe certifies the following:"I certify that n the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." ++ The applicant st call f all required inspect- s. C p1 a drawing on reverse side. Date: ? D2� —� I �F�,A i Title: O Signed „_.; �, r> WOODW f2R• C:`LY CONS F D RT NT ONLY i„ _ •: Date '�,...f Application Accepted.liy, Dates{ Date Final Inspection by Pit or Grout Ins ctioy„ Additional Comments E ,^? ❑ Stk 466 6781 ©.^Irodi i 3621 ; ❑ Manteca 823-7104 ❑ Tracy 835 6385/e Applicant Return all cop_4 t Environrriert"aI Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., 9 ^< �' * DATE PERMIT N0. C RECEIVED BY FEE AMOUNT DUE AMOUNT REMITTED INFO ` + EH 13.24(REV.I/e5) ° �E7 • �.5 �`�/ EH 14-28