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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 LeT d-r- R-L-Ceeb (Complete in Triplicate) piQ7ea 'fo 1977- 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 incompliance 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. Job Address //fir% S /Ylc/liw��rr City F•C. Lot Size -3 AL PM Owner's Name A6l.^-ra n ^zfr_� Address 230-3 Pht aS4A/T & 4zt/ STA4.(fhmii `.473-196-r ContractorFLo-t'D Gina Address-7— A/, AD6/--del' License No. �7�SY76 Phone d "3 97/ TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER 0 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 0 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing g, ❑ Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications \L f'1 Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout _ I I Inigalion _Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done Ll Type of Pump H.P. Slate Work Done Well Destruction 0 Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') t\` TYPE OF SEPTIC WORK: NEW INSTALLATION A REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence� Commercial_ Other Number of living units: Number of bedrooms 3 Character of soil to a depth .1 3 feet: SA IUD Water table depth SEPTIC TANK I? Type/Mfg C e -P 9-� Capacity if 7-0 0 No. Compartments Method of Disposal PKG. TREATMENT PLT. 0 1 Distance to nearest: Well JrO Foundation /Or Property Line /O' LEACHING LINE Ll- No. 6 Length of lines 3 - 70 Total length/size 2 ! r FILTER BED ❑ Distance to nearest: Well Foundation !S r Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 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, 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Completes drawing on reverse side. Signed XTitle: Date: O[ n OR DEPARTMENT USE ONLY t� Application Accepted by �xc_w 'I� -� Su,b o- •A Date Area Pit or Grout Inspection by C/ Date , / Final Inspection by f ,/ / Date Additional Comments: •2�77/Q�/ 2 -7U1["rL /L< ,d, �1, 4- L. 02,7G �K.�•K '17�C. y/Z �'� 0 Stk 466-6781 0 Lodi 369-3621 0 Manteca 823-7104 0 Tracy 835-6385 ,1 Applicant - Return all copies to: Environmental Health Permit/S,rvice1901 E. zelto Ave., P.O. Box k., C / J lesmeV NFO OUNT DUE FEE AMOUNT REMITTED CA1SH RECHWO By DATE �np PERMIT NO. •�r.`I\�\t�''�- . EH I}29 IREY.fix sl a EH lx 2e