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k Y APPLICATION FOR-"PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 1� Telephone(209) 466-6781 PERMIT EXPIRES I.YEAR FROM DATE .ISSUED s {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 r 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 3 Local Health District.. T' PM L?M' D City Lot Size Job Address F Owner's �ame _ Address Phone } - t �r ��/) �Jfj� - —�'� License No.j Phone z Contractor 5 $ JAddress r2l,-- TYPE OF WELL/PUMP: 1 NEW WELL,. WELL REPLACEMENT{ DESTRUCTION ❑ PUMP INSTALLATION A, SYSTEM REPAIR;� � OTHER C] ' ! DISTANCE TO NEAREST: SEPTIC TANK �''T— SEWER LINES D SPOSAL FLD. PROP. LINE F00NDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO ❑ Industrial Q;Open Bottom ❑ Manteca Dia. of Well Excavation_ / pia. of Well Casing T of Casing 15Z Specifications Q Domestic/Private � Gravel`Rack ❑ Tracy Type g '-�- ❑ Public OOther, ❑ Delta Depth of Grout Seal � - Type of Grout G I N Irrigation o7i7&pprdx. Deptfl Ll Eastern Surface Seal Installed by r I H.P. State Work Done Repair Work Done ❑ Type of Pump -- Well Destruction ❑ WelltDiameter ... 1 �'�� Sealing.Aatbri 4(WPo 50'1 ' r :1��. ilier Material RBelow;50'1 Depth . TYPE OF SEPTIC WORK: j NEW INSTALLATION ❑ REPAIR/AflDITION1,3 DESTRUCTION 0 allo septiclable its tem emitted if public sewer is Installation will serve: Residence L-- Commercial, Other ' 6 Number of living units: ' Number of bedrooms "k �� .-Water table depth I Character of soil to a depth-of 3 feet: 14� Ciirti Compartments apacity SEPTIC TANK n/ Type/Mfg No. Method of Disposal G PKG. TREATMENT PLT. ID, I I t Property Line Distance to nearest: Weiii Foundation _ 1 Total length/size LEACHING LINE ❑ No. &{Length of lines r FILTER BED 1] Distance to nearest:' Well- •- 4fi Foundation Property Line ` :•Size Number SEEPAGE PITS [I Depth , :�ft. ; ❑ Distance to nearest_— Well' `. Foundation Property Line R SUMPS DISPOSAL PONDS ❑ / r ' I hereby certify that 1 have prepared thi;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 Ldcal Health District. I Home owner or licensed agent's signature certifies the following:,!,certify thatIrl the performance of the work for which this permit is issued, I shall no i employ any person in such manner as to became subject to workman s compensation laws of California."Contractor's hiring or sub contracting signature certifies the following: u certify that in the performance of the w'rk for which this permit Iis issued,1 shall em�loy persons subject to workman's compensa- I .tion laws of California." f { The applicant s r required' n" Complete drawing-on r r side.-r _ _ _ Date: g Si ned !) Tom- } FOR,P. P,AIMT ENT USE ONLY 1 b . } �, i " 4 �Area i Date Application Accepted by � I. ) Date Final Inspection by, Date Pit or Grout Inspection by ll - -- � Additional Comments: 77 s3 ar 1 _ -Stk-4666781-----© Lalli=-3i 3G21...��-Jb-Mant'eca-823*104--0 Tracy � Stk., CA 95201 Applicant- Return all copies to'Environmental Health-Permit/.Serviices OD1--E-Hazelton-Ave..-P O,�Box-2009, 4 a. kN1 FEE AMOUNT Dl1E A 0 NT FlEdITfEU� ` CASH RECEIVED BY L DATE PERMIT NO. INFO IQ0 97-�%p r EH 13-24 IRM I i a 51 C, F EH 14-25