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4 ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT j 1601 E. HAZELTON AVE., STOCKTON, CA 4 Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED + y * r (Complete in Triplicate) ,, f • �, 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. for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. f Job Address City / � D y /� f'� � Lot Size PM �vcJ/z�� inls7 d77 p Owner's Name Horlr�� Ay�� Addroess /'D �OX 701 pCrK7-04/ Phone yDOQx pal ATS-� %(� •VT� " Zcc!ax, ��Contractor res o a I�A6g814- . Phone TYPE OF WELL/PUMP:_ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �^ —'— PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE,TO Ni EAREST:,SEPTIC TANK !�� SEWER LINES 1 , DISPOSAL FLD. PROP, LINE -..FOUNDATION AGRICULTURE WELL OTHER WELL—.PITS/SUMP,_ _AT' ENDED-USE °"STYPE"OF WEEL -` ('ROBLE-M AREA'. -CONSTRUCTION SPECIFICATIONS 's _ r ❑ Industrial. ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Pia. of Well Casing i�Dom�estic/Private D Gravel Pack El Tracy Type of Casing Specifications rj P bIic ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation Approx. Dept�h+ ❑ Eastern Stj{f ce Seal Installed by t Repair Work Done ❑ Typb--tf Pump V U$ 'H.P. �a _ Stat Work Done 1 �{ I� £ Weil Destruction-, ❑_ .._._..Well,Diameter Sealing Material [top 50'1 �U 8 �D TO of . A Depth Filler Material {Below 501 TYPE OF SEPTIC;WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) 10 �) Instaflation will serve: Residence_ Commercial_ Other ✓ tom" Num tiej rof`ving units: Number of bedrooms v, Character of soil to a depth of 3 feet:, Water table depth SEPTIC TANK � ❑ Type/Mfg Capacity No. Compartments ! C� - PKG. TREATMENT PLT. ❑ Method of Disposal ; { Distance to nearest: Well Foundation Property Line 4 LEACHING LINE ❑ No..& Length of lines ' "* ' 9 Total length/size . FILTER IBE ❑ Distance to nearest: Well Foundation Property Line�Z I c SEEPAGE PITS ❑ Depth Size Number =" ' } rSUMPS ❑. Distance to nearest: WellFoundation Property Line DISPOSAL PONDS EJ ia► I'h6febyJcertify=theta-fiave,prepared'this application and that the work will he done in accordance with San Joaquin county orUiraai"Ices, state laws� d��t` rules and regulations f the San Joaquin Local Health,District. , Homefowner or licensed agent's signatureFcertifies the following',f'I certify that in the performance of the work for which this permit issue, Is at employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sic"`coral acting si�riature certifies`the following: "I certify that in the!. rformance of the work f6r which this permit is issued, I shall employ persons subject A"—Z k an's co nsa- tion laws of Califor is-' [ 1he applicant u t all .alh re spectians. Complete drawing on ase side. Signed ° Title: , c 1 t:l? /4 0' �O Date: FO EP74RT ENT USE ONLY Application Accepted,by i`9 E Date Area ' 1 L1 � -- �Pit�r`Gi-o u"t-siaection�by Date Finµ Inspection by Date Additional•Comment: Q Stk ;46,6-6761 ❑ Lodi 369-3621 .C7 Manteca—623-7104 > —❑`•Tracy-835---6385- A,plicarit Return all copies to: Environmental HeaEth.Peiinif/5eniices:1601 E. Hazelton Ave., P:0. Box 2009,Stk., CA 95201 t FEE., i INFO` AMOUNT:DUE �-- ^" AMOUNT'REMITTED^ CASH RECEIVED BY DATE PERMIT_'NO. + EH13-24 1 REV.I/a 51 �. EH 14-28