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APPLICATION FOR.PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. OAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. Job Address _ I n /4�� - City I t/lJ Lot Size PM - Owner's Awl A`dress 2qTl-1'i i� Phone,'V J Owner's Name 1+�r�=ALV �KQ.r�. Address y'. + } _j_ � Contractar��7�r`� � ��' �-a Address .Q• ih�C�KK 70"iicense No.43? Z' Phone TYPE 0PI'WELL/PUMP_ #NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ V i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE,TO'NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 17 Manteca Dia. of Well Excavation Dia. of Well Casing 4 EI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public . El Other ED Delta Depth of Grout Seal Type of Grout II ❑ Irrigation —1--Approx. Depth ❑ Eastern Surface Seal Installed by i, Repair Work Done ❑ Type of Pump H.P. State Work Done i Well Destruction ❑ Well_Diameter Sealing Material (top-50') -- 4 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: 'NEW INST LLATION REPAIR/ADDITION ❑ DESTRUCTION Ll (No septic system permitted if public sewer is available within 200 feet.) ..- Q Installation will serve: Resiid,ence_ Commercial Number of living units:A Number of bedrooms . �} Character of soil to a depth of 3 feet: C�,/i, l =_ 4 _ Water table depth a� ,, . :�, ' Capacity �;.. p_Y SEPTIC TANK I� Type/Mfg �+� �No..Com artments PKG. TREATMENT PLT. Ll ; f t f I 1 `Method of Disposal r m Distance to nearest: Well 4V Foundation ' Property Line F LEACHING LINE ❑ No. & Length of lines — Total length/size M F FILTER BED ❑ Distance to nearest: well 10 Foundation 550ZL Property Linea y'.� " • 4 SEEPAGE PITS ElL Depth 2 Size 3 3 `1 rY w tNu `ber j<` n 1 SUMPS EJ Distance to nearest: Well Foundation - Property Line y� y i. � i1 '�— e 1i "� 4ffi, 34a r DISPOSAL PONDS ❑ YF F I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, to 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" which this piarmit 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 California." The applica st call or all re 'ed ns tions. Complete drawing on reverse side. 1 , Signed Title: >r� c. �l?'\t"�✓' Cr�a'VDate: Z g 3 c� k f FOR DEPARTMENT USE ONLY Application Accepted by Date —Z'�OTJ '' Area _ Pit or Grout Inspection by Date inal Inspection by ff Date rlkokflm Additional Comments: 9 G �z Tirb I D l�[r �«•,!� vo El Stk 466-6781 odi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835 6385 b`( 6VO4,,_ Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 . FEE .H AMOUNT DUE AMOUNT REMITTEDCA5H RECEIVED BY DATE PERMIT NO. r 'INFO + EH 13-24 IREV.1/95) - L4�...V-3 91-7 `'7� �'T 6 �R5 -','-{5 EH 1428