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M APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Z�opy Telephone,(209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED ` (Complete in Triplicate) Application is heisby 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 .. f. Job Address 5t de. r �'' � City Lot Size PM ��p pE h`l 1 ` ` �D I box 23 �C �nsz�� toy951-370 Owner's Name,�%Jf. 98,61L ��R.,5 . Address !!� Phone e License No!'L1 Phone /`J 37D� Contractor I 1 Address FA&i Z-15 TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION B PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f t DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION —.AGRICULTURE WELL OTHER WELL PITSISUMPS 'rte INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing ❑ Domestic/Private y❑ Gravel Pack 0 Tracy Type of Casing Specifications (7 Public F1 Other Cl Delta Depth of Grout Seal -Type of Grout Y I i Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ' • REPAIR/ADDITION I I DESTRUCTION t I Wo septic system permitted if public sewer is * available within 200 feet.) Installation will serve: Residence k<1C0mMeFciiaI.__ Other c ( Number of living units:_L_ Number of bedrooms 3 1 ' ! Character of soil to a depth of 3 teat: 01,40666Water table depth SEPTIC TANK. JW Type/Mfg Cfl Capacity No. Compartments e � l PKG. TREATMENT PLT.Elr -).- Method of Dispos$I Oisfance to nearest: Well Foundation Property kine r LEACHING LINE 00 No.& Length of lines Total length/sire r. FILTER 9ED ❑ Distance to nearest: Well T ZI +-Foundation Property Line L? I SEEPAGE PITS '� Depth Size Number SUMPS L7 Distance to nearest: Well j_Foundation Property Line DISPOSAL PONDS ❑ !` ` _ I hereby certify that t 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 owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or subcontracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The-applicant mfor all required inspections. Complete drawing on�treverse side. 9-30-87 r Signed X_&2;� - -- Title. c tWn � _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area I I it r Grout Inspect" y to / Final Inspection by Data Additional Comments: Cl Stk 46 6781 ❑ Lodi 369-Pt321,:-' 0 Manteca M-7104 C7 Tracy 835.8385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk,, CA 95201 n f FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE INFO PERMIT"N0. - a EH 13-24 IREV.r/est * -,.�.ao .L Or dV 1 Y.( 1 Z V r it • rC3 i EH 14.2[1 �- v