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r.. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA " Telephone 1208) 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.50 for sewage or No. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address T If cityM1&A:221�._ Lot Size PM Owner's Name Address-IlF4SO4 �s�z Y1 _ 7q 0042tJ!Oed-Phone // License No v JE.;��r7z fi - ' R-.iL CO- Address `� brI'767 ryt- _ . 3�8'2_�(P Contracts Phom _ TYPE OF WELL/PUMP: ' NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION 0 '--'- 1- PUMP INSTALLATION`D SYSTEM REPAIR 0 - 'OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE — FOUNDATION' ' AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED UStk, _.TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r.F. ❑ Industrial ,n;'iry : ❑Open Bfman ❑Manteca Dia. W Well Excavation Dia. of�ell Casing 0 Domestic/Private I O Gravel Pack El Tracy Type of Casing Speciflcatidns .4 fl Public `\,` - t_1.-CI Other 0 Delta Depth of Grout Seal Type of Grout I I largation �� _Approa. 0ap6t_ I l Eastern Surface Seal Installed by 'Rspair•Work Dom 10 Type Of Pump H.P._ State Work Oona— J Wee Destruction J+OWell Diameter-. Sealing Material Itop 501 . ' ,Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I1 (TION I I DESTRUCTION I 1 (No septic system permitted if public sewer is ^� p q available within 200 test.) Installation will serve: Residence_R-Cafimarciat_ Other - Q Number of living units: Number of bedroom Character of soil to a depth3 feet: Ar --- Water table depth .� SEPTIC TANK O Type/10,19. Cattachy No. Compartments ' r PKG. TREATMENT PLT.0, .Method of Disposal Distance to merest: Well Foundation PropartY Line LEACHING LINE LSI'No. & Length of lines _ _ / Total length/size A O FILTER BED 0 Distance to nearest Well�QtQ Foundation Property Line SEEPAGE PITS t I Depth ''Size Nu r SUMPS & Distance to nearest: % Well, /. O)i Foundation /D f Property Lim DISPOSAL PONDS ❑ r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, siat¢•laws, and! rules and regulations of the San Joaquin Local Health Di3trict. Home signature owner or licensed agent's signare 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 became subject to workman s iomPonsation laws of California."Contractor's hiring or sub-contrec ting signature certifies the following: "I certify that in the performance of Me work for which this permit is issued,i�twlhe^nPioy persona subject to workman's compensa- tion laws of California." + The applicant must all for all required inspections. Complete drawing on reverse side. - r It, Date: V rtM1-,fC/.,�0_ Tkle: _ Oate: Signed K --T-- r _ - / FOR OEPARTM USE ONLY Date�/ Araa-rL--2 - . Appltcaqon Accepted by I,/7- �'y '� I � rou i p4ttion tlY Data , Final Inspection by' - Date 21 Additional Comments: ' 0 Sit, 466-6791. 0 Lodi 369-3621 0 Manteca 623-7104 O Tracy 835-6385 �^ Applicant - Return all copies to: Environmental Health Pemvt/Services 1601 E. Hazelton Ave., P-O. Box 2009, Stk., CA 95201 FEE K RECEIVED By DATE PERMIT'NO. INFO AMOUNT DUE AMOUNT REMITTED CASH I�I� 85-315 b _ _ ..EH 134 rREV.vxsi EH tfs a. _