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t , APPLICATION FOR PERMIT JOAQ 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. v q 1 Telephone (209) 466-6781 DATE ISSUED / a3 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/Dump and the Rules and Regulations of the San Joaquin LocalHealthDistrict. Job Address �& .S�4, S' 16,d&j U Subdivision Nam y Phone Owner's Name HOFF/y/A/V d Se.tLS'Address .ZLS4�i' 30' Phone 5.73'�/-7 7' oQ Contractor's Name .C' As�Tfa.>;r�H License No. TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ C SEWER LIP. LINE NES DISPOSAL FLO. PRO DISTANCE TO NEAREST: SEPTIC TANK OMER WELL PITS/SUMPS FOUNDATION AGRICULTURE WELL On NSTRUCT[ON SPECIFICATIONS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT[ of Well Excavation - Industrial ❑Open Bottom ❑Manteca Dia, of Well Casing LI Domestic/Private ❑Gravel Pack ❑Tracy ❑Public ❑Other ❑Delta Type of Casing IrrigationApprox. C3Eastern Specifications E]Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by H.P. tate Work Done - Repair Work Done ❑ Type of Pump - Well Destruction [j Well Material (top 50')Well Diameter Filler Material (Below 50') Depth (A REPAIRJADDI710N ❑ (No septic tank or seepage pit permitted if public sewer is TYPE OF SEPTIC YORK: NEW INSTALLATION�I available within ZW feet.) Installation will serve: Residence _ COMMarcial — other Number of living units: Number of bedrooms Lot size Water table depth _ .! ! a J Character of soil to a depth of 3 feet: Capacity Y /.ZOO No. Compartments SEPTIC TANK ® Type/Mfg ar C^< — Capacity Method of Disposal �--- PKG. TREATMENT PLT. ❑ Type/MfgProperty Line foundatfon ' SEWAGE SYSTEM a Distance to nearest: Well ie { [„ OESTRUL110N Total length/size No. & Length of lines � Property Line LEACHING LINE well Dia Foundation .�.�__ FILTER BED C] Distance to nearest: Number __,_----- Depth Size __� property Line SEEPAGE PITS C1 Foundation SUMPS ❑ Distance to nearest: Well DISPOSAL PONDS ❑ oce with San Joaquin county 1 hereby certify that I have prepared this apPlicatjon and that the work will be done in acct nce of the work for which this ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. sat ion laws of California." i certify that in the performance of the work for which person in such manner as to become subject to workn thii�compen Mane owner or licensed agent's signature certifies the follopin9: I certify that ^ permit is issued, I shall not r�p1oY a"Y,P n laws of California." Contractor's hiring or sub-contracting sn9nature certifies the foil owing: this permit is issued, I shall employ Per50ns subject to workman`s compel Complete drawing on reverse sjde. pate- The applicant m call for 1 required inspections- Title: Signed % DE ENT ll5E ONLY D-7 ❑ Stk 466-6761 y� fJy" A� ❑ Lodi 369-3621 Application pccePtetl b ❑ Manteca 823-7104 Additional Comments: Date �// � /f ❑ Tracy 835-6385 Pit or Grout Inspection by Date L.ei-=� Box 95201 N p,p_Tracy 2009, -6385 CA Final InsPetttan by Health Permit/Services 1601 E. Hazelton Ave.. Applicant - Return all copies to:. Erviroixnen DATE PERMIT N0. RELEIVEa BY AMOUNT WE AMOUNT REMITTW EE I BASE jE27 3- 11 '`1! INi0 10/82 500 EH 13-24 REV. 10/82 14-26