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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT • 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 i' 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l (Complete in Triplicate) t aosquin Local Health District for a permit to construct andlor install the work herein Application is hereby made to the San Jdescribed.This application is 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 made Local Health District QQ `W `Q1Q*i�__ ` ` 'D City S r,CdZ Lot Size ?.o �QG'eES PM Job Address GL C' TAGlCrm !Z Phone Address Owner's Name t9 Contractor E GJOO Address 7 4/ ADE`t6EQT License No. z�'7,S b76 phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES —�— FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications r r ❑ Tracy Type of Casing I Elbomestic/Private O Gravel Pack Depth of Grout Seal Type of Grout.. f-1 Public 71 Other ❑ Dana + ?. . I I Irrigation -Approx. Depth I I Eastern+ tl - Surface'Seal Instalted.hy^' r Q'— .L_. n Repair Work Done ❑ ITe -- of Pum H:P'. —State Work-Do- t'Pe yp sealing Material Itop 50'1 Well Destruction ❑ Well Oiameter� 9 E _ ,.�Dapth LC Filler Material (Below 50'1 TYPE OF SEPTIC WORKS Nfi�Ws NSTALLATION REPAIR/ADDITION 1 1, DESTRUCTION I I availaOPelwitthi 20feet.) ' ed it public sower is 7E L�:YI ST/ilio GOAT Gf ..2•BLO.'sE'd f. t Commercial '/ Other t i. Installation will serve: Resi80n e ( - Number of living units: _ t Number of bedrooms Water table depth Character of soil to a depth f 3 feet: ° _ I ' SEPTIC TANK �YPe/Mfg GC _ P9C'L Capacity L4 DO• No Compartments Z t ? Method of Disposal f PKG.TREATMENT PLT. O, f go z I Property Line . r Disianceine 'd" arest: Well JOO� Foundation b •Z - g�z ' Total length/sizes r LEACHING LINE No. d Length of lines FILTER BED E] Distance to nearest: Welt X00 Founi dation fi'� Property(Line t _ Size - ---'�y� Number _ O SEEPAGE PITS' -j 1�1 Disith. �. / Foundation_ — Property.Line SUMPS a ; 4r,-0 'Distance to nearest. Weil ,,.. j DISPOSAL PONDS ❑I- -- I hereby certify that 1 have prepared This. ficatiWartd 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 Nktrict. Hoare owner or licensed agent's signature certifiesahe following: "I certify that in the performance of the work for which this permit la issued. I shall not I empby,any person in such Anne as to become suh�jiitt 1p workman's compensation laws of Cal fornia."Cwitractoes hiring or subcontracting signature certifies the fallowing:'9 certify that in the performance of the work for which thisli7fmiCis i3sVetl'f3Kag�m6lby persons subiect to workman's compensa- ton taws of California." +� The applicant must call for all required inspections. Complete drawing onveverse ride. iy/ Tide: ��#• Date: -7-14--R Signed, ^+� i } FOR D,€PABTMENT USE ONLY � r (�/f _ n�.�g�J Area ` t1 . 11 Application Accented by Date �ytd Date 7d Date Final Inspection by A f Ph or Grout Inspection by\_ .. '�•_ __ �y Atldigorial Comments; racy835-1085 • ❑ Stk -�By�1 copies to Environmental 1 ❑ Manteca firm 706 Stk., CA 95201 e a Q�jy,y Applicant � Return all capias to: Environmental Health Permit/Services 7607 E. Hazelton Ave., P.O. Box t - d+xa^aa CK RECEIVED BY DATE PERMIT ND.' a! FEE AMOUNT DUE AMOUNT REMITTED CASH INFO x.EH 1}at(REV.v x m . EN 1h1a