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} APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT !I• 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. R'3-•(Z2.Lj Telephone (209}•466-6781 DATE ISSUED 3 -i23 PERMIT EXPIRES I YEAR FROM DATE ISSUED k (Complete in Triplicate)^ �. I,!1 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 1 and the Rules and Regulations of the San Joaquin Local Health District. Job Address 17,57�e4tof �- Subdivision Name i Owner's Name d�- " �Address Phone yG d- +r.9'6 Contractor's Name Q- A9 yM.,J 21 . License No. Phone tu/C. TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION❑ PUMP INSTALLATION SYSTEM REPAIR OTHERL. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES- DISPOSAL SPOSAL FL D. �'\' PWOOy LINE — y F0UNORTiON AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial kA J�EKcayaSiop_. N_ +11 a H;U Domestic/Private E]Gravel Pack ❑Tracy ! Dia. of Well Casing Public 0I1Other E3 Del to Type of Casing ,�L.rl Irrigation '< Approx., Eastern ' s Oe s ti tJ Specifications \��t++ 't\ A th. 1y Cathodic ProtectiAn +? D � m Geophysical - Depth of Grout Seal , i Other+. Type of Grout �.-.__-.—Surface-SeaL.In sta itad.by Repair Work Done ❑ fType'of-Pump' State Work Done Well Destruction-0 Well Diameter SealingzMaterial (top 50') _ Depth Filler Material (Below 50'), 1 k 0 TYPE•.OF SEPTIGiIdORK: NEW 1NS7ALLATION ❑ REPAIR/ADOI7 (ION (No septic tank or seepage,pit permitted if public sewer is � �.*r available within 2O0 feet.) GI Installation will serve; Residence-+sX� _Commercial Other Number of living units: �'%*_""umber of bedrooms t Lot size #4&P__A)Ct l^ Character of sail to a depth of,3.fee%Aver.4 A X : Water table depth SEPTIC TANK 'C.J Type/Mfg t Capacity ; No. Compartments PKG. TREATMENT PLT. [] Type/Mfg Capacity ""v Method of Disposal SEWAGE SYSTEM " Distance to nearest: Well /,go r Foundation 3 D Property Line•.. DESTRUCTION ❑ , % f i s LEACHING LINE LLJ No. 8 Length of lines J.- i�Oy Total- length/size• +' �'� FILTER BED Distance to nearest: 'Well 10PAr0 I Foundation ! Property Line SEEPAGE PITS Depth 2,1-f Size. ,� / Jiumber + SUML0 PS EJ Distance to nearest: Welt Foundatioh�SOI : Property Line V DISPOSAL PONDS + i +.. .. I I hereby certify that ] have Prepared this application and that the work will be oboe in accordance with San Joaquin County ordinances, state laws, and rules?and regulations of the San Joaquin Local Health District. + .j Home owner or licensed agent's+signature certifies the following: "I certify that in the performance of the wprk'for which this 1 permit is 1,sued,.I.shall not_elaploy any person in such manner as to become subject to workmant compensation laws of California." i 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 compensation laws of California." . The apDlit t call for all, re ired tions. Complete ete draw' =n`r erse,sida. aaarnnnggg...mmm/��s �YC� Signed ��izi_] `Title: - /IENT iNLY s• ' Application Accepted b Area E ❑ Stk 466-678 Additional Comments:tb4y ' r ❑ Lodi 369-3621 . .lam' Pit or Grout Inspect % Date �� ❑ Manteca 823-7104 , Final Inspection by +r • ""•'^^----°•De>*e;-rd-'�L -^-•' ❑ Tracy 835-6385 , Applicant - Return all copies tironmental Health,Permit/Se'rvices 1601 E. Hazelton Ave.,,P.,6 &`-x 2009, Stk., CA 95201 • .\ 1 � s v,} sit FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIaAL4 INFO �S O . .' '.'� \ r- 10/82 500 EH 13-24 REV. 10/$2 i:.,y(wa +•"•++w 14-26