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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 W CSF P PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in Triplicate) 3 3 3 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 eb�1 made in compliance with,San Joaquin County Ordinance No.549 for sewage or No. 1861 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.:.,.. '`r lflet �} I et<XIS�4"5 + '/r0 /— Job Address ) rIc' OT ��y� y�' _ city � /D� Lot Size l�fJpM c Owner's Name �'� 1�! Address Phone e 1 1u oX /g� Licensd-k t36.10 4 •Phone ContractoraS�� rkAo Address x`17-Z NE'11V WELL '❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ + TYPE OF WELL/PUMP: ti ,. .�•- 'Y- HER Yar i 5 > PUMP INSTALLATION ❑�' .� '" SYSTEM REPAIR ❑ +� BOTHER © y� DISTANCE TO NEAREST:,SEPTIC TANK SEWER INES DISP6S.Z, FLD. PROP. LINE e FOUNDATION AGRICULTURE WELL. -OTHER WELL PITS/SUMPS INTENDED USE M TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 15Manteca Dia.-of Well Excavation w-�- -Dia. of Well Casing LDDomestic/Private ❑ Gravel Pack ❑ Tracy �. Type of Casin Specifications ` ❑ Public ❑ Other f Cl Delta Depth of Grout Seal Type of Grout ` rox Depth Eastern 4 �. Surface Seal Installed by _ ❑ Irrigation __ App Repair Work,Done ❑) Type,of Pump H.P. � State Work Done Sealin Material (to 50'} WellDestruction ❑ Well Diameter 9 p '`\ Depth ( Filler Material (Below 50') { f I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No naptic system permitted if-public sewer is _ � available witFiin 200 Installation will serve: Resi ante Commercial Other 41 Q �°=r}'o't �r � I Number of living units: i Number of edrooms � Character of soil to a depth of 3 feet:i Water table"depth' C'r� s `+'i SEPTIC TANK TypelMfg F e-C r Capacity 0 o No. Compartments } '} sG �� Method of isposal P,LF1t , !� PKG. TREATMENT T. _,j,,� f t �t/ + i * � Distance to nearest: Welles foundation�� - Property Line�.�-- `I- k LEACHING LINE No. & Length of lines rt Ofclam length/size— FILTER BED Rf Distance Ito nearest: Weil /jwf,- Foundation t4G t Property Line SEEPAGE PITS ❑ Depth 11 !2 -Size , Number r SUMPS Distance'to nearest: Well Foundation Property Line� �_ DISPOSAL PONDS ❑ 1 I 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 :e 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, l shah not t 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 isiissued,I shall employ persons,subject to workman's compensa- tion laws of Califo ia.' t i 7 f The applicant call fol all requirednspections. Complete drawing on roverse:sid y ' Title: Date: Signed - r >:.. 1 FOR DEPAR ENT USE ONLY ' I r _ o Application Accepted by l Date Area - t } Date Final Inspection b Date C Pit or Grout Inspection by i 3 Additional Comments: � . ,- - p Stk-AW6761--•-� ❑ Lodi L 369-3621•-------{]-Manteca-823-7104----�-�-Q Tracy rt "95201' Applicant- Return all copies to: Environmental.Health Permit/Services 1601 E. Hazekon Ave., P.O. Box 2009, Stk., CA 85201 p E CK _ ,. -�- -FEE- AMOUNT DUE —AMOUNT REMITTED CASH RECEIVED BY'� DATE PERMIT`NO. INFO - 3 - + EH 7324(REV.1/851 f EH 14-25 „_ O