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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT .p � 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-8781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r� (Complete in Triplicate) ; a� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein'deftribed,•This appOeatian N xis . made In compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for welt/pump and the Rules and Regulations of•tfia San Joaquin'f,, Local Health District. . Job AddressL� /S.5—(Ze�; WCiry .Lot Size PMr' - #" „y. ,. J OwnM Owners Name � ��--"TT1�ifFaddress , 64XPhone i � . `. Contractor 'Address 11 License No TYPE OF WELL/PUMP:'—NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO ,❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER-'CI - r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP LINE $ FOUNDAT!0N AGRICULTURE WELL - OTHER WELL PITS/SUMPS 4 `rt ty ' '.INTENDED USE TYPE OI-'WFLIL PROBLEM AREA 'CONSTRUCTION SPECIFlt3ATIONS ❑9lnduadial; ; """-'p'Operrrot!om ❑Manteca-; * Dia.of Well Excavation Dia.of Well Casing � •+f CF Domestic/Private ❑Gravel lack ❑Tracy Type T of Casing -'CI Public - <- t❑Otlye ❑Della Depth of Grout Seal tr_ Type of Grtnet ❑irrigation' G, Approx.Depth Q Eastern �` Surface Seal Installed by ''�+ s a" �,• ` Repair Work Done D Typeiof Pump _ni t H.P: y ' State Work Done' Wen Destrucslon t ❑ WeII 0immeter "Sealing)0latenal(top,50'I. ---r. r i Dap'.h a Allier Material[below 50'I :TYPE OF SEPTIC K: MclN INSTALLATION❑ REPAIR/ADD DESTRUCTION❑ (No septic-system permitted if public sewer is available within 2L'9 feet,l- r Installation will serve: Residence-j- Cornmercial Other Mumber'of Wing units: Numller of bedrooms IN. C1t*r*eter of soh.to*.depth of.3 felt: '' E Watei table depth SEPTIC.TANK Q Tyne/Mfg' Capacity ..froi Compartments. Ple'G.TREATMENT PLT.❑ r.%1 Metfiod of Dieposa!' ' "t1 ty µ4- Distance to nearest: Wel! '•� FoundationM�?►oiler y Line = 'LEACHWGLiNE"'"""' No..3lRngth'ottin�s F Totatlength/size + i FILTER YEDp '. z q';bietarrce to nearost:�+:Well /! .�Y Foundation y� Property fns' .. � ,r ...ty, la # •� fir'';'" /_�� SEEPAGE PITS ❑ Depth V,, Size _Seize "r Number /p W IPS gam ' Distance`to neaiest: ' 4x Well' Foundation Property,Liner DISPOSAL PONDS .�..., .._.. ? } ,1 hereby certify that I have prepared this applicetfon and that the work will be done in accordance with San,'Joaquin cotlnry ordinances;state laws *rid T 3 r ,.`, b rules and reguletlons of the San Joaquin Local Health District. N $'I, `'t Hame owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is 4sued,i shah employ any porton in such manner as to become subject to workman's eompensation•laws of California."Contractors hiring or sub-contractfng signatuis o certifies the following:"I certify that in Aie perfornance of trio work for which this permit is issued,I shall employ 009"S subject to workman's eomrpertas tion Laws of Caiifomia."tr ` 1 t ; :!: .frte . R: 77 'S 7;*7 T!a applicant must can forin tions.Camplete.Erawing on revers side. Signed . Tkle: \y Dte y �Gr�fa } FOR DEPARTMENT USE ONLY r * r Ix Application Accepted by, --_ Date '/ / t Area E �! IS Prtor Grout Inspection byDate Final Inspection by Additional Comments. i = ©Stk 488-ml '❑L&I 388-3821 ©Manteca 823-7104 ❑Tracy M648396 e t A ail plebesnt-Retum, epphs to:Errvironmerttai Health Permit/Services 1801 E. Hetalton Ave., P.O.,POBox 2009,Slit.,CA 116201 ^'•�'^'�"Y"w;.:a...�..'.:. i�FEE AMOUNTDUE.*,: -AMOUNT REMITTED .: .x:.G r: r� RECEIVED BY.� `- •NFO GASH DATE PERMI'rNo 1....-.iw,...,...:. .. i�-.,. --...a......,rw.... �z.h�, #"" a EM 13.36 WEV.ri-Sl �� t� -t �� ' f'j` - T Errta.3ta �.7 �frL11�b _ -Y �w•.MY.cF�, _i.'rt �i'_t;r� �v n, -� , �r,,,ge'.-- : :..,,_ �� ' - 'tiQ6 +.� �.