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r y, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA f. Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED '- (Complete in Triplicate) tV`a..c.. ""�- -- � Application is hereby made to the San Joaquin Local Health District for a permit to construct-ar d/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. } Job� Address r �j R '� City � ©e � /Lot Size�� J(oLW ply' jf Owner's Name Address 2,0 � die—P,140,01 Phone I; l 1C.t )XI ' p E Contractor C9 f Address ��gp.�� OC �fi) License fVo_:�QJ 7Zr Phone 360 IB . TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION d "rr PUMP INSTALLATION'❑ j'SYSTEM1RE-PAR_B -- -- - O1-HER 17 t.: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. -+ PROP. LINE iR! FOUNDATION _ .,AGR1ClJLTURE WELL�'! OTHER WELL �%-' PITS/SUMPS _ "—'INTENDED USE TYPE OF WELL PROBLEM AREA CDNS fRUC rI ECIFFCATION! ❑ Industrial ❑ Open Bottom ❑ Mafiteca t. Dia of Well 6cavation ,_ 3 � i �- "�� Dia of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy , Type of Casing Specifications { FI Public Cl Other (' r �t - ' r ❑ Delta Depth'of out Seal Type of Graut _ I ! Irrigation A rox. De th I I Eastern //// — pP p. ��, Su�aca�eal'fnstalled_by, )Repair Work Done ❑ Type of Pump H.P. � � State Work Done__ E f Well Destruction ❑ Well Diametert "" """"�" Sealing Material;{top 50'1 --'--q=.✓ � Depth Filler Material(B ow 50')— -- — f C� f ii`� TYPE OF SEPTICIWORK: NEW INSTALLATION Vrr EPAIR/ADOITION.4l=I-DESTRUCTION I 1 (No septi system permitted if �/� public sewer is g} �� available within 200 feet.) I Installation will "serve: Residence Commercial_ Other Number of livinjg units: Number of,bedrooms , f` I Character of,soil to a depth of 3 feet: Water table depth d i SEPTIC TANK t11�T e/Mf '"' `'" g C® APC-, =E. e ' '-=Capacity f DQ No. Compartitfenis s PKG. TREATMENT PLT. ❑ �n r to 6 Q Method of Disposal Distance to nearest: Well Foundation\11 I Property Line LEACHING LINE No. & Length of lines Ql r res Total length/size f FILTER BED ❑ Distance to nearest: Well C� ( FoundationPro art S r p y Line - I' SEEPAGE PITS DepthSizewN6mber I SUMPS ❑ Distance)to nearest: Well�7�?1 Foun�da�tion..-I f\ _ Property Line 101 l DISPOSAL PONDS ❑ i t I hereby certify that I have prepared this application and'that the-wo�W'wil�IiUl-be done in accordance with San Joaquin county ordinances, state laws, and I rules and regulations of the San Joaquin LocaP Health'DrItrict. ` 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_Galifornia."Contractor's hiring or sub contracting signature certifies the following: "I certify that in the.performaoce of the work for which this permitis issued, f shall employ persons subject to workman's compansa ' tion laws of California." !y fes",�r The applican ust call for all squired insptfctions. Complete drawing on ev" area side,' Signed X Title: tle: Date: FOR DEPARTMENT-USE ONLY Application Accepted,.by Date`- ( � J .. ., Area y Pit or Grout Inspection + �Final InspectiDate / Z Z Date _ on by Additional Comments: "� 1�i?.r� ih� t✓C y-� Yt ❑ Stk 466 6781 ❑ Lodi�369 3621 ❑ Manteca 82317104 ❑ Tracy 835-6385 Lor Applicant- Return ali ta: Environmental Health Permit Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 In CcJ� ; f. ,z ,,— k �4, de� IF FEE z AMOUNT DUE # AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CAS r� y +,EH1a- (REV.i/k5] ( (' �c �: 3� 2 +-S: ' ti