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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT L� L 1601 E. HAZELTI ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 } Jab Address ) r ' Ci Lot Size 35,1cre PM. Owner's Name iSSA C Y1So Address ,- - - FFhone� � ,.. ✓�--^-(..3 - O�Q Y1,�3�.Cb Ll Contractor' •Lcense No. s,�--?�3y Phone Lj�` va 1 Contractor's N e TYPE OF WELL' PUMP: NEW WELL ❑ j WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO N�AREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE IMPS,'FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �i! ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing , ❑ Domestic/Priva e ❑ Gravel Pack _v:: ❑ Tracy Type of Casing Specifications ❑ Public j ❑ Other I'/- ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ___4ppro.*'Depth ❑ Eastern Surface Seal Installed by Repair Work Done. El Type of Pump H.P. State Work Done Well Destruction ;❑ Well Diameter . Sealing Material (top 50`1 � Filler Material (Below 50'1 �`._ - .-._.....� � .Depth _ tt TYPE OF SEPTIC NVORK: NEW INSTALLATION —REPAIR/ADDITION ❑ DESTRUCTION 13 (No septic system permitted if public sewer R available within 200 feet.-)" . Installation will rve: Residences Commercial •Other- :1 Number of-livin' units. Number of bedrooms., �,1 Character of soi to.1.a depth of 3 feet: — - _eater.table,dept ` SEPTIC TANK f ❑ Type/Mfg 72 -t—CA Capacity 0 No-Compertments� f PKG. TREATMENT PLT. ❑ Me%fiod--of`Disposal Distance to nearest:.1 JWell �Foundation Property Lines 1, �* LEACHING LINE f No. & Length of lines _�i '"' } % .� dotal length/size /0 , FILTER BED ❑ Distance to nearest: .� Well Zoe Foundation __— Property Line Z SEEPAGE PITS ❑ Depth Size y Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t hereby certify that I have prepared this application and that the work will be done in accordance with Sart Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin 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 workman's compensation laws of California."Contractor's hiring or sub contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." r•� The applicant mus for all required inspections. Complete drawing on reverse side. Q� Signed Title:JLS eL^�_! fes. Date: �� ! FOR DEPARTMENT USE ONLY Application Accepted by Date A Area Pit or Grout Inspection by C9a1 Date Final IrysrTby f4 Date ib �� . vi f > Additional Comments: S 10 ❑ Stk,466-6761 ❑.1:6di- 3pg 1 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental-Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CLASH RECEIVED BY DATE PERMIT NO. INFO !¢ S +EH 13-24 IREV.10!831 '_70 �� { L►t, EH 14-28