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APPLICATION FOR PERMIT sts C: sk `bf� SAN JOAQUIN LOCAL HEALTH DISTRICT .}oEa Z3-`�o(p0 -0 f 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplete 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 r 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 Di�st�rict. Apo Job rens`' _, OLAA'e 1 City Lodt Lot Size PM Owner's Name �le4yt>''l,t° PtJf',05 Address gS'96 cove J rfGc.Kk4it sPs[ll sQ►`S Contractor ddress 29 ZS jffl- &I e- t e License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT a DESTRUCTION L PUMP INSTALLATION © SYSTEM REPAIR t_1 OTHER X c-,r2�"J, 1AOri,A 5 � DISTANCE TO NEAREST: SEPTIC TANK 7 52 r SEWER LINES :�Z SDf DISPOSAL FLD. `PROP. LINE /01 FOUNDATION Ste' AGRICULTURE WELL loar OTHER WEI,L?�Ql_ PITS/SUMPS L~ # INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 71Manteca Dia. of Well Excavation ft t Dia. of Well Casing L Domestic/Private ❑ Gravel Pack L Tracy Type of Casing f)A- Specifications •; L3r_Aar- lS I'1 Public Ll Other F1 Delta Depth of Grout Seal 53' Ntya<41z Type of Grout 1 i Irrigation _..Approx. Depth I I Eastern Surface Seal Instafled by fnyl'YG r _ � Repair Work Done 0 Type of Pump H.P. State Work Done Welt Destruction ❑ Well Diameter # Sealing Material Itep 50'} Depth Filler Material (Balow 501 v = I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIWADDITION i I DESTRUCTION ! i (No septic system permitted if public sewer is i available within 200 feet.) 111JJJ Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms IV Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK D Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS L Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ l I hereby certify that I have prepared this application and that the work will he 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 lawsof C 'ornia." The appl" nt st call for all aqui d ' pections. Complete drawing on reverse side. Signed X Title: Date: _ F R DE RTIIAEIIT USE ONLY - Application Accepted by Data ~� Area Pit or Grout Inspection by Date Final Inspection by Date 5' - Additional Comments: i r El Stk 4666781 ❑ Lodi 369-3627 C1 Manteca 823-7104 ElTracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA �a4 We4_e_nt v f+Oct FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT No. �t}/43• ' FH 13-24 IREV.1/k51 �q � s 18 Ir! -EH 14-28 9l-cap .-