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s APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 F Local Health District. Jf Job Address _� City_# XCgtJW Lott Size PM { Owners Name OY bH Yy�M Address Phone `-1 111 _ .45 Contra_ for .4 N7 Afs -ry <'AW _Address v ✓M A-V Or License No. Phone— y4X1 TYPESF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION L-1 PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE . FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing _ � Specifications Cl Domestic/Private ❑ Gravel Pack Tracy Type of Casing [-I Public C) Other Cl Delta Depth of Grout Seal Type of Grout I I 1 Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by H.P. f'`'' C7 l State --p&—Done— Repair _p& Done Repair Work Done J Type of Pump x: I Well Destruction ❑ Well Diameter ... ?;;, 4'Sealing Material Ztop 50") t�^a i��C .��i2a .r, [�pih` Filter Material (BeOd I TYPE OF SEPTIC WORK:1 NEW INSTALLATION V REPAIR/ADDITION l I DESTRUCTION i I INoseptic system�perr?titted if putilic sewer is available within 200 fest.) �7 i Installation will serve: Residence Commercial �Other __ k Number of living units: Number of bedrooms �f O�t Water table depth l i Character of soil to a depth of 3 feet: � Compartments �SEPTIC TANK LA Type/Mfg �Cpy r' �'t�i z Capacity p } 1 __ _ _Method of Disposal. PKG. TREATMENT PLT.fl Joe iDistance to nearest: Well F47 Foundation fr Property Line LEACHING LINE Or No. & Length of lines Total length/size 00` Foundation .IRS" Property Line r0 FILTER BED Distance to nearest: Well --- - Size yX rX �P -- Number SEEPAGE PITS 1,1 Depth O0 Pro Line SUMPS W Distance to nearest: Well /a O Foundation�� pertly DISPOSAL PONDS ❑ I hereby certify that 1 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 oyvner,or licensed agent's signature certifies the Wlowing: "I certify that in the performance rn the work for which this permit is issued, 1 shall not employ any person in iuch manner as to become subject to workman's compensation Taws of California."Contractofs hiring or sub contracting signature certifies the following:{'1 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;j" f The applicant mus alldor all required inspections. Complete drawing on rev Se si e. tr-b'-90 Signed _ Title:_ -- Date: R DEP TME T ONLY I Date Application Accepted by Data �-Final Inspection b Date Pit or Grout Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Q Manteca 823-7104 O Tracy 835-6385 �.�,; Applicant • Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2W9;Stk." CA 952!)1 _ CKRECEIVED BY DATE PERMIT'NO. FEE AMOUNT DUE AMOUNT REMITTED CASH. r.... INFO �) / ..r, `1��-�t��i �l Z,Gj q� r' � ✓5 ..EH 1124 IREV.1/"51 EH 1.6