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i fi ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELiON AVE., STOCKTON, CA ' I Telephone (209) 466-6781 r' PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heleby 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 Dissttjricpt. Pm owner's q�on A C 1 I d �'l AY I I YU ) CN of Size oU YC- Job Address JA Cir Owner's Name .y- I ' �'�Qrt✓-)m F)'fdQVLCk Address 1176 J- V GL✓C+ Soh E)TAM Phone 3�_0 nn7t To ,g x.5165 510J q$ � 0 Phone ContractorAddress 4�[ ' TYPE OF WELL/PUMP: II NEW WELL -1f9 WELL REPLACEMENT ' DESTRUCTION PUMP INSTALLATION IN SYSTEM REPAIR ❑ OTHER ❑ v.,�O DISTANCE TO NEAREST: SEPTIC TANK . _-- SEWER LINES 150 DISPOSAL FLD.._C11_ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE YYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS All ❑ Industrial - ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private GlrGravel Pack ❑ Tracy Type of Casing—:F V L r Specifications �1 elir f7 Public ❑ Other ❑ Delta Depth of Grout Seal /00 Txpe of Grout— Ir /rvCII l/YL It tit% I I hrigatiooIIII Approx. DepA th I Eastern Surface Seal Installed by Relw f I 11 MCW Repair Work Done O Ty'e of Pump H P• Srate Work Done_ i ' Well Destruction Or Well Diameter 31, Sealing Material Itop 501 C Depth 801 Filler Material (Below 501 TYPE OF SEPTIC WORN: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I availaeptic syin 200ermitted if public sewer is ii le Installation will serve: Residence_ Commercial_ Other Number of living units: r— Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ' SEPTIC TANK ❑ NNN Type/Mfg Capacity. No. Compartments PKG. TREATMENT PLT. O !I Method of Disposal li Distance to nearest: Well Foundation Property Line 1 ' LEACHING LINE LII!No. 8 Length of lines r Tota! length/size Pro Line �FILTER BED ❑ i Distance to nearest: Well Foundation Property ' SEEPAGE PITS I I,j�Depth Size Number SUMPS LI IIII Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑II 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 agant's signature certifies the following: "I certify that in the patio rmence 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 signatum, certifies the following:"1 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa ' tion laws of California." The applicant must call for all required inspections. Complete drawing on averse side. Signed .. TDate: I 'f FOR DEPARTMENT USE ONLY ' Date Application AccepU y ? /`_- -T Area d �6 ' Pit or Grout Inspection by Date Final Inspection by Date a Additional Comments: C3 Stk 4666781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy f135-6385 ' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �I FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N�yo. ,y a/ INFO m 11' /�.I�' �1I'^I/,+r / ry_� .� /1t^J/JIV/I.`� a.EH 13.24(REV.r�xSi �� 4` 1 I0 141 1 Al y I ry�/�I�—' (] f, /ypy/�f� ,41 EH tr 26 ,!l 10 1-1;I VL1 "FI