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APPLICATION FOR PERMIT ON JOAQUIN LOCAL HEALTH DISTR• 1601 E.. HAZELTON 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.�,� 2595 2Y eM � SS 33� PM Job Address ►�� C1ity TraPc'.vI� Lo11t�S11ize Q-G f�Rc n froAU&S �6 . Address ��pNL �C' ^�� Phone 5.x'-14 " Owner's Na\mAeL ,, S•Oh M��,f�,CD C� C�. p Z -7q— 430 74 Contractor v �� Address Y•C)_Beit 33C 19% Vl� SCA. License No. 58I 1 Phone TYPE OF WELL/PUMP: NE WELL 2S Y/ge �ll tipr�1WELL REPLACEMENT ❑ DESTRUCTION ❑ �-�(` j�y-, �7-�Vw `' PUMP INSTALLATION ❑ exN'h SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK Nk SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELLN&_ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation — Dia. of Well Casing I s< Type of Casin L 4o '�/L Specifications ❑ Domestic/Private ❑ Gravel Pack h. Tracy 9 (-1 Public F.1d Other t1 Delta Depth of Grout Seal � Ty a of Grout Irrigation -SS��Approz. Depth 1 Eastern Surface Seal Installed by dhJ�� Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial_ Other Number of living units: _ Number of bedrooms - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ��11/{PAY Meth.�o7d of Disposal Distance to nearest: Well Foundation rzRdl AWN R E C E.'"5. LEACHING LINE ❑ No. & Length of lines Tp l Ag a sisN FILTER BED ❑ Distance to nearest: Well Foundation ropertrty Line SAN JOAQUiN (AUNTY U SEEPAGE PITS I I Depth Size SUMPS Ll Distance to nearest: Well Foundation �ropermy Line DISPOSAL PONDS ❑ 1 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 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 laws of California." The applicant st call fo all quired inspections. Complete drawing on reverse side. Y /� t2,1 U Title: D""'-�`3" Date: [" yi,,—A Signed X_�ctf1� — C FOR DEPARTMENT USE�ONLY ^r� O Date �� f / Area �3� Application Accepted by Lr `�'� ,,( , N Date Final Inspection by �' '\ Date W Pit or Grout Inspection by ! ' ' '" 'w / v Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 / Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2(109, Stk., CA 95201 FEE CK RECEIVED BY GATE PERMIT NO. !� INFO AMOUNT DUE AMOUNT REMITTED CASH ..EH 13.241 REV.Ix 51 U ` � EH I'M