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N r APPLICATION.FOR.PERMIT SAN JOAO,UIN':LOCAL HEALTH DISTRICT 1601 E. HAZEL TON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED I s(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 Focal Health District., �� a r r i /JolbAddress ( r` City r `�rLot Size PM_ yr - Qwner's Name '�-tz rJ 1"i V , Phone `f I ntract,Ar's Name C TA IN 1 Lice . � =L— T Phone17 TYPE OF,WELL/PUMP: i1 . NEW WELL tWELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATI ` "' z SYSTEM4PAIR ❑ OTHER ❑ t� r DISTANCE TO NEAREST: SEPTIC TANK SEWER_LINES DISPOSAL FLD. DROP. LINE FOUNDATION AGRICULTURE WELL OTHEWWELL `PITS/SUMPS INTENDED USE TYP WELL PROBLEM AREA CONSTRUCTION SPECIFECOI,jS�L ❑ Indust1rial pen Bottom ❑ Manteca Dia. of Well,ExcavationCec-ifications . of Well Casing ❑ Do tk/Private ❑'Grayel'Pack C1 Tracy Type of Casing S ,� ublic` ❑ Othe_ ❑ Delta (Depth of Grout Seal T� a of Grout ❑ Irrigation Approx.. Depfh ❑`Eastern t..._ _ :Surface Seal installed by - Repair Work Done ❑ Type of Pumper 1 H.P. State Work-Done Well Destruction ❑ _Well DiaTeter Seal Material (top`V) j Depth l Filler-Material (Below 501)4, TYPE OF SEPTIC WORK: NEW,INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No.septic system permitted if public sewer is available within 200 feet.) ` ='lns[allation wilt serve: Residence_ Commercial Other 1 ;; 1. f si4 r �'w Numbdr of living units: I Number of bedroomsi� J Character of soil to a depth of 3 feet: �'-' '% "' f i- _z ' T `Water table depth i SEPTIC TANK ❑ Typal Mfg �t Capadfy' ° W «. No. Compartments PKG. TREATMENT PLT. ❑ t ' `-%. — Method of Disposal i Distance to nearest: Well a J Fpundation; 4 Property Line , . t LEACHING LINE ❑ No; & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGL PITS ❑ Depth _ t—Size - -- I Number SUMPS ❑ Distance to nearest:. `Wall t,. Foundation 'Property Line ( ` DISPOSAL PONDS —M 1 hereby certify that I have prepared this application and that the:work,lvill be done ins accordance with San Joaquin county ordinances, state laws, and ' rules and regulations of;the San'Joaquin Local Health District. Home owner or licensedkagent�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'mariner as to become subject to workman's compensation-laws of-California."Contractors hiring or sub-contracting signature certifies the following:"I'cRh ' e performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of Ca'ornia."The app/}can s call r pe i . C mple drawing on rev f Signed Title: Dater ` FOR DEPARTMENT USE ONLY 3[ Application Accepted by �';,� "� � Date Area _.._ � Pito Grout Spec tion by V ate V anal Inspection by__ Dots Additional Comments: _,fj .:t 1 ,.. .ti. w .+ ••c. .:�,.+r ,a1 ,� � .` f ..s h �_- t -�. '^.c ,..-v;•mc� _ - ❑ Stk 466478]' 4❑ Lodi a'369- kll t; _1� Manteca 4104---- 0 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601,E.,Hazetton Ave., P.O:-Box,2009, Stk.,.CA 95201 J.# I .._, FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO CASH + EH13-241REV.101 J 831 IMP EH 14-28 1 � 6