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I APPLICATION FOR PERMIT. SAN JOAQUIN LOCAL HEALTH DISTRICT • `� 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ! (Complete in Triplicate) a permit to construct and/or install the work herein described. This application is Application is hereby made to the San Joaquin Local Health District for made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for welt/Dump and the Rules and Regulations of the San Joaquin Local Health District. I Job Address City Lot Size 2/0 Alf r PM_...._ E .C �-"�'f'Y ,_ Owner's Name dK Address Phone i I Contracts Ig vi •i- � Address .9be1 License No.�Phone ( TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT U DESTRUCTION ❑ I ( PUMP INSTALLATION Q- SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE t I I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ._ 11 UNTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS # ❑Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑1Domestic/Private ❑ Gravel Pack 0,Tracy Type of Casing Specifications 1 I Public ❑ Other ❑ Delta Depth of Grout Seat Type of Grout_. kI Irrigation ir —.Approx. Depth 1 1 Eastern Surface Saul Installed by ; - I Repair Work Done .❑ Type of Pump ---. H.P. State Work Done 1j 1 z. WeIP Destruction 'f ❑ Well Diameter Sealing Material (tap 50 Depth Filter Material(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION V REPAIR/ADDITION i I DESTRUCTION 111No septic system permitted if public sewar is y available within 200 feet.) V ./ of Installation will serve: Residence—60" Commercial_ Other �r'r+"' Ilk'` Number of living units: i Number of bedrooms ' .Character of soil to a depth of 3 feet: '57%k4,Uc 7%k4,,UcL t.&A.&, Water table depth Q 7 SEPTIC TANK Ik'Type/Mfg A& a�6 6 4 e- Capacity goo& No. Compartments C"NG. , Method of Disposal z ' "PKG.TREATMENT PLT.❑ O Distance to nearest: Well.�,� Foundation_71L— Property Line LEACHING LINE [21--No. & Length of lines ` 1 .—A S t r 2 - Total length/size FILTER BED ❑ Distance to nearest: welij�7Pa. Fodn�tio� Property Line I SEEPAGE PITS (Vbepth —S_sl ✓L� Size / Number SUMPS ❑ Distance to near%C Well O r Foundation �/QQ-1_._ Property Line DISPOSAL PONDS ❑ -- I hereby certify that I have prepared-this application and•that m"e work will.be'dbne in.accordance with San Joaquin county.ordinances, state laws,and r rules and regulations of the San Joaquin Local Health District. I .%l �' I -"J . Home owner or licensed agent's signaturecertifies th�.fdlWggi_g:„rl certify thatin the performance of the work for which this permt is iswed, I shall not ertP)jloy any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature r certifies the foaowing:'I certify that in the Performance of the work for which this permit is issued.I shall employ persons subject to workman's compensa- i tan laws of Caltfoinia." 11 l r The applicant must call fo all r9quired inspections. Complete drawing on reverse side. Sigt �,F��(Ate. f /!1 r U/ ned x / �.Si9g:(`/�%w� `Li .. Date: r — GGVV t f. P FOR DEIfART ENT USE ONLY Application Accepted by Date Arae ��(U.�p-� t,or Grout Inspection by a e �a final tnspettion by _ Date f AdLhional Comments: ❑�tk 466.6781 E3 Lodi 369.3621 111 Manteca 023-7104 ❑ Tracy 835-6385 i Applicant-Return all copies to: Environmental Health Parmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 • 'e`er-. ____.� _ _...-.P.- INFO T AMOUNT DUE AN(ILINT REMITTED CK ��'i flECEIVED BY DATE PERMIT NO. _ ., 'CAVI t EH la-]I IREy.vnel 70 � 7V 0 Of , �f—��g vo I ER 14,211