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APPLICATION FOR PERMITD (� n SAN JOAQUIN LOCAL H"ALTH DISTRICT u 11011 1601 E. HAZECTON AVE., STOCKTON, CA Telephone 12091 466-6781 MAR 9 i1$7 PERMIT EXPIRES'1 YEAR FROM DATE ISSUED-Iro ^t I NVIROMENTAL HEALTH _ (Complete in Triplicate) ipERMIT/SERVICES i., ., App8ca0on Is hereby made to the Sen 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. 1882 for well/pump end the Ryles and Regulations of the Sen Joaquin Local Health District. .. .MgOit7 i� .,.. _ - .. . Job Address Lot Siza - Owner's Name �'a0'Z-Q- • a Address Ll ��: :: LSCCif • .M1 ^�� �J�j. / y Phone Contracts �//��[. � 1 2 ��.,L�/�sr.l�i 94 •/j9-�/ / Address a �c �r �rr-, Phone B TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ - DESTRUCTION ❑ PUMP INSTALLATION ❑ rF1J1 SYSTEM REPAIR ❑ OTHER.B' .�DISTANCETO-NEAREST..SEPT.IC,7A NK—-� SEWER LINES DISPOSAL FLD.. ,PROP. LINE,_ _ FOUNDATION AGRICULTURE WELL OTHER WELL PhTS/SUMPS Q INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia, of Well Casing .kr Domeatic/Private ❑ Gravel Peck ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ❑ Irrigation �� TYPO Of Grout —_Approx. Depth Eastern Surface Seal Installed by "•`7. Repair Work Done ❑ Type of Purrip� H.P. / State Work Don Well Destruction ❑ Well Diameter jy Sealing Material (top 501) F Depth Vj Filler Material (Below 50' TYPE OF SEPTIC WORK: NEW INSTABLAAT,ION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑11Nb aep0c system permitt d if pu is se r ' f�r .yavailabi� In 200 A Inategation will serve: Residence_ C rnor martial_ Other 4.. .its-►tom• Number of(Hing units:_ Numbs r=of bedrooms 4—:' �. Character Of soil to a depth of 3 feet: 1.`' SEPT TANK 1.--0--7 Water table depth ype/Mfg.�j-- »-gapacity- —_.__— No.-Compartments-- PKG. TREATMENT PLT.❑ 'v Method of Disposal Distance t nearest: Well r_•i! ` I I Foundation - Property Line z j LEACHING LINE ' A r ., ❑ No. & Length of lines Total hngth/life FILTER BED ❑ Distance tc nearest: ll' WeFoundation `•-� .1 r Property Line SEEPAGE PITS ❑ Depth r - Size Number SUMPS a--. -❑ -Distence-to nearest:.. Well " Foundation DISPOSAL PONDS ❑ - . . Property Lina I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ofdinancw, at rules and regulations of the San Joaquin Local Health District. ate laws, and 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 subcontracting signature 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 compense. tion laws of California." t1( The applicant�9�+s�t ca for/yaI/k re.�gw�red inspections. Complete drawing on rre/ery�]J��e__{{�6a side. Signed Xl_`L� � lf�Yir✓�L� t Title: per; i 1 FOR DEPARTMENT USE ONLY �c Application Accepted by "� _ (y A� /11 //7 � �'' Datet,.��1 /� V Pit or Grout Inspection by a Date Final Inspection by!r! ,,,.,,,,,��n11.��' Date 7` Additional Comments: ❑ Stk 4e8-8781 ❑ Lodi 38,9,9621 ❑ Manteca SM-7104 ❑ Tracy 1 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,"Stk, CA 96201 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY .,:DATE. .PERMIT NO. EH1a (REV.1i61) EH 1426