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APPLICATION FOR PERMIT " F SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA lam" ! Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4 (Complete in,Triplicate) E 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. Job Address X90 3 A&soar _ City ��oear°.� :Lot Size--' - PM Owner's Name I'1 R !/RR�9�Pn1�HsL _. Address. 2 Q03 lyf• ltl 1/S�d�/ s ^11 •"i (Phone - �lG 0.3 r t r Contractor Sc 1_,F Address ___ ___License.No., _ Phone TYPE OF WELL/.PUMP: NEW WELL.0 ___T ELL REPLACEMENT ❑ DESTRUCTION ❑ • 'PUMP INSTALLATION r❑- ..rix -SYSTEM REPAIR"O "'" OTHER ❑ f DISTANCETO NEAREST: SEPTIC TANK SEWER LINED ALIF L D. I PROP. LINE f FOUNDATI6 "!C"' l ! rAGRICULTURf YKILL OTHER WELL PITS/SUMPS INTENDED USE- TYPE OF WELL PROBLEM AREA CONS CTIONiSPECIFICATIONS 1 El Industrial ❑ Open Bottom 11 Manteca of We xcaiiation Ola-ofgWell Casing O ❑ Domestic/Prir9ate ❑ Gravel Pack Ll Tracy Type of Casin �' Specifications a EJ Public /�s ❑ Other ]{Delta Depth of Grout al 3 Type of Grout II ❑ Irrigation Approx; Depth ❑ E ern Surface Seal in, by r f Repair Work Done ❑ Type of.Pump H.P. &,State Work Done r Well`Destructibn' 1-1 Well Diameter Sealing Material {top 50'1 ,Depths Filler Material Melow 50'1. J-4 I (TYPE OF SEPTIC WORK:%,NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRU� IO { m o septic6systepermitted if public sewer is _i, . vailabldiwithin 200 feet.) Installation will serve: Residence'.I. Commercial Other Number of living un}s: Number of bedrooms Character of soil to a depth of 3 feet:1+f Water table depth SEPTIType/MfCapactty2B � S No. Compartment C TANKs f PKG. TREATMENT PLT. ❑ � r ` Method of Disposal ` Distance to nearest: Well r. Foundation .Property Line LEACHING LINE ❑ No. 6 Lengthy of lines Total length/size l FILTER BEDS ❑ .Distance to nearest: Well Foundation�O Property Line Al 1 1'r + SEEPAGE PITS Depth 6CFT Size 2 Number SUMPS Distance to nearest: Well Foundation ;Property Linen , Dl!;POSAL PONDS ❑ vglge 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. 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 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 Californial 4, } must calk for all re ed inspections. Complete drawing on reverse side. Rh k C, Dcant Ar Title: d Date: FOR DEPARTMENT USE ONLY `S .., Application Accepted by Date Area Pit or Grout Inspection by t Date Final Inspection by Date Additional Comments- w n2 c'2 ' I►?11!e. ,T f ❑ Stk 466- $1 ❑ nodi 3 3621 ❑ Manteca S 823-71 _ ❑ Tracy 835-6385 G Applicant - Return all copies.to: Environmental Health Permit/Services 1601'E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 c .c I INFO r WOUNT DUE AMOUNT REMITTED ` 'lagCtf) RECEIVED BY DATE PERMlVNO. 4 + EH 14-241REV.t/H51 }L # QQ, w- `.k •� ` �� Z —92 f. £H.14-2e v `