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APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.IHAZELTON AVE., STOCKTON, CA eiephone (209) 466-6761 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED- (Complete in Triplicate) It 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. t - ' , - I , . .1+ w„ ,r dH_qv .. . . Job'Address 2aS74P �9GL/O77-JC- `. CityLot Size PM Owners Name 241 AI 1`7-.f n1Qli1.- Address �" E" - ''-5 ,Phone r� Contractor FLe VZ7 Address /<D-Ir Al, L/LL.lALJ 4Ve1_icense No. 4flt'Y7L Phone ' TYPE OF WELL/PUMP: a NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR.0 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS_ ❑ Industrial O Open Bottom t❑ Manteca Dia:of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy', Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Easter Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. t State Work Done Well Destruction ❑ Well Diameter '.Sealing Material 6013-509 Depth Filler Material(Below 50') 0(1 TYPE OF SEPTIC WORK: NEW INSTALLATION Er REPAIR/ADDITION ❑ 'DESTRUCTION ❑ (No septic system permitted if public sewer is + available within 200 feet.) 0 • Installation will serve: Residence_ Commercial_22!!�Other �✓Gs2./r�, m Number of Irving units: Number of bedrooms Character of soil to a depth of 3 feet: Water cable depth L� SEPTIC TANK ' TYpe/Mfg Capacity 12-8 o No. Compartmeins 2- PKG. TREATMENT PLT.❑ - "dr- Method of Disposal Q Distance to nearest: Well 71,0 Foundation /Or Property Line .50O rf- "IJL�•. LEACHING LINE Na.t1eho of lines .2— O x ^r Total length/size Ze ' "I FILTER BED ❑ Distance to nearest: Well J19 Foundation ?- Property Lim—4e� / — � Ott SEEPAGE PITS M Depth S Size 3 3 �r'` Yr Number '1 SUMPS ❑ Distance to nearest: Well!GO,4 Foundation /e0 Property Line , -DISPOSAL PONOS ❑ / I If I 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 Lam]Health District. Ham owner or I'icensed 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 pe,sons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing rannmverse\smde. i Signed X_�_ I/iS^t.-aY `• Tide: f" Date: /D—2•r'— - - f. FOR DEPARTMENT USE ONLY (5—z Area 1 APPIiceYwn A.by � (I�rT7 4, Date,� � Area �l v E-1) er Grout'Inspection by Date ;-ml Inspection by Date' m Additional Comments: • ❑ Stk 466-6781 )�Lodl 30-3621 ❑ Mantece 823-7104 ❑ Tracy 835-M Applicant- Return all copies to: Environmental Health Pernh/Services 1601 E. Hazelton Ave.';P,O. Box 2009, Stk., CA SMI �N FEE AMOUNT DUE AMOUNT REMITTED COAK3H RECEIVED BY DATE PERMIT'NO. INFO' '1 � � 1'11 �+ •EN.1331 iMa•.r/661 4J'�' 1.��'�'" .. 10�1,j �5 FN i434 1