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f APPLICATION FOR PERMIT IIS r" SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL T ON AVE., .STOCKTON, CA 'i Telephone (209) 466-6781 r E PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) �. Application is hereby made to the San'Jt oaquin 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. r' C{ W V 9f (.l.0" Lot Size 1 1 ��`".' PM t Job Address:' � J d / l�f t f 7 City T -Owner's Name �lY��'� Address 9p Phone s (X, 04-con =Phon Contractor Address License No. WELL REPLACEMENT ❑ DESTRUCTION ❑ I TYPE 0F,'WELL/PUMP: NEW WELL Ll ; PUMP INSTALLATION r-7SYSTEM REPAIR LJ OTHER ❑ DISTANCE.TO.NEAREST:..SEP_TIGTANK —SEWI;ER LINESN- _DISPOSAL FLD. -PROP. LINE., FOUNDATION •AGRICULTURE WELL OTHER WELL PITS/SUMPS -� INTENDED USE `TYPE 0r,WELLkN 1�1PROBLEM'AREA CONSTRUCTION SPECIFICATIONS 1 Dia. of Well Casing 4 ElIndustrial f LiXpdn.Bottarg 'r''grLMan#eca iia_of-W&Il Excau6twn g + -� Specifications ❑ Domestic/Private Gravel Pack µ '❑6Tracy Type of Casing pe 'fl Other ❑"Delta Depth of Grout Seal Type of Grout + ❑ Public M } g --Approx. Depth ❑ Eastern; Surface Seal Installeh by I s ❑ Irrigation op Pump State Work Done Repair Work Done ❑ rTYpe mmp -„� _ r,.f Welt/Destruction O Well Diameter _ "" r "� Sealing Material (top-501 i 1 i Depth I -*' Filler Material (Below 50') # TYPE'O SEPTIC WORK: NEW INSTALLATIO �.REPAIR/ADDI'jION ❑ DESTRUCTION {No septic system permitted if p6 blic sewer is ` PCS available within 200 feet.) Installation will serve: Resiclence Commercial ��TNbe !?' r of bedrooms_- ` + Number of living units: �r # �,� :,". Water table depth , Character of soil.to.a depth of 3 feet: �. "Capacity` No. Compartment SEPTIC TANK r':�Type/•Mfg., - i T PLT. ❑ t' � Method of Disposyl PKG. TREATMENT "°► r _;�� F c`3: 0 _ Property Line Distance to nearest: Well Foundatibq �No`.&=Len th of fines t - 0' Total length/sigro ze LEACHINdLINE st ,% ! _ tea , a,.r / -f0 FILTER SED�IS4 +�❑. Distance to`nearest: Well Foundation { �— Property Line i is • Nurpber SEEPAGE PITS Size.j B�Depth ; SUMPS ❑ Distance to nearest: vVel! �O � Foundatia� �' Property tine c DISPOSAUPONDS ❑ i m ' �--"" s _", k s I hereby certify that I have prepared this applicat+on,and that�the work will be done`in acco;ance with San 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 followirig: il-certify that in ithe performance of the work for which this permit i3 issued, I shall not employ any,person in such manner as to become subject to workman's compensation laws of C,elifornia."Contractor's hiring or sub contracting signature certifies the.following: "I certify that in theiperformance of the work for, this permit is issiied 'I shall employ persons subject to workman's compensa- tion laws of California." The applic 4 all for nspections. Complete drawing on reverse side. Signed:,f �/�""r `.�"'-rG'!�^""" Title: Date: _f --� + FOR DEPARTMENT USE ONLY t4, Date ,. —,eZ Area Application Accepted byl::-&-d y , '` at Final Inspection by Date `7 TZ ; Pit or Grout Inspection by t- Additional Comments: ❑ Stk 466-6781 O-L-odi-369-3621——❑-Manteca--823=7104—❑"Tracy 835 fi3%""'-'"`----- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 n AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.1/85) !�1 �UU S � V�C77I _r-)0� EH 14.26 '