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I rt APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT M 1601 E. HAZELifON AVE.,-,STOCKTON, CA Telephone (2091466-6781 f . .� r:� f•^, qtr., � y �'3 ..,}, . PERMIT EXPIRES'1 YEAR.FROM DATE ISSUED 4 + h± SCom plete: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 _7962,' vim-, N V` ` F i City atnL4, Lot Size I --I PM Owner's Nam r E' Address `7 9 t i�y D • �=Phone _� Contract r Address p C ! License No._3.7V-72(a Phone �i ooo -Slo 6 t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ F . PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _P INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Ot4r ❑ Delta Depth of Grout Seal Type of Grout ❑ irrigation ---Approx. Depth ❑ Eastern Surface.Seal Installed by _ A I —Repair-Work-Done—El -Type.of.Pump.------ �---'--'^--'-�=State-Work'Done"""`�'�-" Well Destruction ❑ Well Diameter Sealing Material pt6p.50'1 -b Depth. Filler Material {Below, 501 TYPE OF SEPTIC WORK: NEW INSTALLATION EP-AIR -DDIT.ION_ —DESTRUCTION-❑-- -s (No septic-system-permitted-if-publicewer-is"" n available within 200 feet.► Installation will serve: Residence Commercial her Number of living units: - . �� Numb�r'of edrooms \ Character of soil to a depth of 3 feet: �� y• f Water table depth . SEPTIC TANK CIType/Mfg Capacity l _. No! Compartments PKG. TREATMENT PLT. ❑ # 17 / € Method of Disposal Dista9nce to nearest: Well -Founda#ion/�/ P1roperty Line LEACHING LINE 2� No. & Length of lines I 7: ` notal length/sizeE x earest: Well + r foundation /� Property Line�S. � FILTER BED. ❑ Distance to n1 - :, r. SEEPAGE PITS ID Depth i - -Size �> �� Numberk SUMPS 0' Distance to nearest:I- Well 400 f- Foundation-4p- —'Property Line DISPOSAL PONDS ❑ I 1 I hereby certify that I have prepared this application and that the, orVwill be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San'Joaquin Local Health Districts 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 wAman'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 applicant must call for aIJ required inspections. Complete drawing on reverse side. j � o Signed Title:_ V �' Date: ti + f` FOR DEPARTMENT USE ONLY Application Accepted by ' / Date Area (� 7 Pit or Grout nspection by t -7 Date`"yr �- Final Inspection by 0--600 Date Gf Additional Comments: li ❑ Stk 466-6781 ❑ Lodi 1 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-6385 Applicant- Return all copies to: Environmental Health.Parmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 � FEE AMOUNT�DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH I, f t EH 13-24 1 RM /H 5) ' I,bQb , 1 'pb `% ,�t .EH 14-28 - is