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e .' -1, 7 APPLICATION FOR-PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT- 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED ; w (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. .+.,:arry:s.:. '' F Job Address ��au ��55av4 1��/'. City & Lot Size PM Owner's Name C.f'!@ r�M - 'Address,3;Z0 f F�5 f o 7'►� , r,scw.u�+ Phoney/�� �+ Cl, 9 ys8 3 g Contractor's Name r' �i.[.r c ��.�� License No.' y�f Phon�r TYPE OF WELL/PUMP: NEW'WELL WELL--REPLACEMENT ❑ ....DESTRUCTION:* "' PUMP INSTALLATION Cl -='�d SYSTEM REPAIR ❑ `OTHER'❑• e DISTANCE TO NEAREST: SEPTIC TANK = SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION—;``-- AGRICULTURE WELL OTHER WELL PITS/SUMPS ; 44 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATJONS PC Industrial 111 ❑Open Bottom ❑ Manteca Dia. of Well Excavation to e 11-- Dia. of Well Casing Domestic/Private -)4 Gravel Pack )S Tracy Type of Casing U L Specifications ❑ Public ❑ Other > i ❑ Delta Depth of Grout Seal T�&v C-t.tee-m,.,erArype of Grout ta4mCms,da x O Irrigation _ —Approx1Depth ❑-Eastern Surface SealdfisIled_by r �G Repair Work Done El Type of Pump H.P. 5 State IIor one Well Destruction ❑ Well Diameter _f Sealing Material (top 501 Depth f :Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION-0, DESTRUCTION ❑ (No septic system permitted if public sewer is Y - available within 200 feet.) t. Installation will serve: Residence_M1' Commercial_ Other J Number of living units: Number of bedrooms Character of soil to a depth of 3 fest: ; Water ytabla depth s� ` SEPTIC TANK LlType/.Mfg_ - �` Capacity� � ° No-:-Compartments , PKG. TREATMENT PLT. ❑ .�f " --Method of Disposal.) -4_- '"�`-&stance to nearest, Well foundation Property Line F LEACHING LINE ❑ No. & Length ofIliPi✓es_ } �- - - -= otat-length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ;: SEEPAGE,PITSr E: Depth I A Size Number SUMPS ❑ Disterice to nearest: Well Foundation_ Property Line a DISPOSAL PONDS ❑ f a 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 Health District. i 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 notY_, + 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." '` k The applicant st call for all requ' d inspect' ns. Complete drawing on reverse side. _€_ 11 _ ir Signed Title: ! Grusrne/rwti l Gr Date: Alt ' FOR DEPARTMENT U5 ONLYT��l`N Application Accepted by Date 4' Date IITi T Area /7 } Pit or Grout Inspection by GiGlfOl�..L Date' l,Z T 1T Ae-,n l Inspection by 3 �Date flZ`T Additional Comments: vv"_` ,est 2 4 "`� ��I�2✓r -�` 1 ❑ Stk 466-6781 , ❑ Lodi 369-3621 IfManteca 623-7,104 ❑ 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 CASH RECEIVED BY, R DATE PERMIT"NO.' INFO yp } 9 /} + EH 13.24 IREV.10/ffi1 �Jyt ! 0 1 jV0 EH 1426