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APPLICATION FOR PERMIT SAN JOAQUIN'LOCAL"HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 ` PERMIT EXPIRES 1,YEAR FROM-DATE ISSUED'41 (Corr ple#e id Triplicate? r ti . tJ? lo. ! Application is hereby made to the San Joaquin Local Health District for permit to construct and/or instals 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 Ryles and Regulations of the San Joaquin. Local Heakth'`District t, z a' w4 : •� r " , 7 �:� 43'�{3a?�' '� •y,r:' " Job Address k� ' `L_4,,,` }_Q `'City`""' Cw ` Lot Size PM' t -,Owner's Name 1-5 414 14 A I'- - Address' - � ::. .':_;' Phone Contractor r �`�/�GCs�2- Address � License No. �!i 5`fit Phone ` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Cl SYSTEM REPAIR ❑ OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE F FOUNDATION _ AGRICULTURE'WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF.WELL PROBLEM AREA aCONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.'of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack` ❑ Tracy Type of Casing ? Specifications ; E] Public ❑ Other " ❑-Delta r Depth of Grout Sea! Type of Grout ❑ Irrigation ---Approx.Depth IT Eastern Surface Seal lnstalled by Repair Work Dane, ❑ Type of Pumpr H. '�� State Work Done Well Destruction [IWell Diameter. ' i Sealing Material (top 50') f t 4•y r { Depth , i';. ''w2 _ w_ 4_ ;- I 1=tiler Material (Be1ow:50'1,.:�. .` _ , ` TYPE OF SEPTIC WORK: NEW INSTALLATION f tFIEPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) n x Installation wifl,serve% :Residence i ke.Commercid --ii*O her --=.' �. �-.<� -' •_.� 4 � ��r-�,_'�:r ;i',y. �.•-.sem',-.:`°,.. �. ffi - -- �4''�y'` Number of living units: Numo4r:of bedrooms_,!-'- G - Character of soil.to a depth of 3 feet: ' � �$� A7'9 T S a,vD^� Water table depth SEPTIC TANK Type/Mfg< `moi /r* ' Capacity � No. Compartments i PKG. TREATMENT PLT. ❑ - 1 i 9 Method of Disposal ! Distance to nearest: Well Foundation �a Property Line mar LEACHING LINE $aNo. & Length of lines' - '-' �- � Total length/size `� FAX a FILTER BED i El Distance to nearest: Well ' Foundation: �� .Property Line y3 A— 1 t SEEPAGE PITS Ll Depth F r` !Size f!� ` ' ��' Number 3 ! SUMPS Distance to nearest r Well Foundation -Property Line DISPOSAL PONDS ❑ t ( t 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 rules and regulations of the San Joaquin Local Healthl!District. " Home owner or licensed agent's signature certifies the1Wl5win6:'"I i:ertffy1hafin 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."Contractors 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." The applicant must call for I requir d inspections. Complete drawing on reverse side. I Signed X rJ -.Title: ro date'- �.�°'1!-' 6---, FOR DEPARTMENT USE ONLY i Z�" 'Application Accepted by --,_ Date 'Area � .1 Pit'or Grout Inspection by ` Date s/ Final Inspection by Date Additional Comm lits: F-1Stk 466-6781 ElLodi 369-3621 „,: LJManteca '823-7104 ❑Tracy Applicant- Return,all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. 66x 2009, Stk., CA 95201 t,! w.� y LFEE-:-y-AMOUNT DUE- AMOUNT-REMITTED CASH:, 1' RECEIVED-BY --^--DATE`.'-`"-"r•-"PERMIT"NO:-*' -' + EH 13-24(REV.1/85) EH 14-26 S -