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APPLICATION.FOR PERMIT _ q SAN JOAQUIN LOCAL HEALTH DISTRICT I� 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (205) 466-6761 ^ 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED L q (Complete in Triplicate) 197. () Application is hereby made to the San Joaquin Local Health District for a permit to construct end/or Install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.649 for sewage or No. 1862 for well/pump and the Rules and'Regulations of the San Joaquin Local Health District. - Job Address 972 /'.Pdfl.Qy "V t9 city.�T2Y G Lot Size PM Owner's Name 1,4� 'f��61,,}�d Address !Phone 6 Q 92- Contractor's Name /°/4.2�lJ�b'i� ! G S License No. 2 SY^3 a/,£ Phone K: L 0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION-❑�" ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 13 Open Bottom ❑ Manteca Die. of Well Excavationes Dia. of Well Casing ❑ Domestic/Private ❑ Gravel PaOk ❑ Tracy Type of Casspg'C Specifleations �+ ❑ Public El Other ❑ Delta Depth of.•Grout Sa�el, y,Type of Gout ❑ Irrigation _-4pprox; Depth ❑ Eastern Surface Seal Installed.,by Repair Work Done ❑ Type of Pump H.P. $tate Wotk Done Well Destruction ❑ Well Diameter Seeli Ing Material (top 601 S Depth I Filler Material (Below 601 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if pbbl'x:sewer is availlable,% In 200 feet.) Installation will serve: Residence iff5Eommercial_ Other..S ' Number of living unite;_/_umber of bedrooms Character of WI to a depth-of 3 feet:: 01-:P4j -v� Water table depth 4,6 SEPTIC'TANK.y' �� ❑ Type/Mfg P/f2/2l.1'H Capacity ��OO No. Compartmental PKG. TREATMENT,PLT:❑ \ ,. y � F r Method of Disposal 'L P i �w�, ./ Dhttence to nearest:' We114 �Foundation �� Property Line �. ] —.moi/`' LEACHING LINE IP'"NO. D Length of lines 7 Total length/size — FILTER BED ❑ Dlstana to.nearesv: Well*_.AA Foundation 49/ . Property Line !{ SEEPAGE PITS' ❑ `uepth )''I, S1ze Number Z SUMPS�' 13,". "frce to nearest: Welt -1 Foundation 16 Property Line DISPOSALPONDS 21 'I hereby.artlfy 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 Iicef sed agents 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 workr,stn's compensation laws of California."Contractor's hiring or sub-contracting signature .certifies the'following:"I certify that in the performance of the worx for which this permit is Issued,I shall employ persona subject to workman's compensa- tion Iawa of California." u he applicantce`I for all required Inspections. Complete drawing on reverse side. Signed X7 ••c ~ .•IA Title: Date: J~ z - FOR DEPAR ENT USE ONLY 0 ApZJ, 402 pllatbn Accepted by Date �� Area 0 Pit or Grout Inspection by le 64, Date Z`7Zr/ Final Inspection by -- Date k Additional Comments: ❑ Stk 488-6781 ❑ Lodi 389,M1 ❑ Manteca IB&9.7104 `.\I%b Tracy `836938.5' > Applicant-Return all copies to: Envhotvnernal Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 ' IF O AMOUNT DUE ) AMOUNT REMITTED CAH RECEIVED BY DATE PERMIT'NO. ♦EM 13-21(REV.10/831 r: � EN 1473 i