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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Josqu n Local Health District for a permit to construct and/or Install the work hehkt daecn1 1 This appflcauor►is made in compliance with San Joaquin County Ordinance No.5"for sewage or No. 1882 for well/pump and the Runts and Regulations of the San Joaquin Local Health District. JJ�� 1- Job Address — -7 7 City�lelot Site_ U PM Owner's Name ��-a-.Ir�._�1J11>l� Address Contractof6lLia AetlAddress`� Y.! �5 _License No. y � Ptmens�+ 77-.•l fG TYPE.OF WELL/PUMP: NEW WELL 1.1 WELL REPLACEMENT G DESTRUCTION ❑ PUMP INSTALLATION Cl SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r-OUNDATION _ — AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PP08LEM AREA CONSTRUCTION SPECIFICATIONS Industrial ' Upen Bottom i_' Mantes Die.of Well Excavation Die.of Wall Casing Domestic/Private i 7 GravN Pack ill Tracy Type of Casing Specification Public "' Other FI Delta Depth of Grout Seal Type of Grout Irrigation __lpprox. Depth Eastern Surface Seel Instated by Repair Work Done Type of Pump _ H.P. State Work Done vwo'n Destruction Web Diameter __, Sealing Material Itop 50.1 Depth _.__ Filw Material(Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION e REPAIR/ADDITION Ll DESTRUCTION U INo septic system permitted If public sewer in N available within 200 feet.) Installation will serve: Residence_ Commercial —J�e" Other _ Number of living units: ___ Number of bedrooms Character of soil to a depth of 3 feet: �r-LL_,�j--- itylco m Water table depth SEPTIC TANK ��p0 Type/Mfg _ Ill__ ,Jf B4__— CapacNo. Co �MtnMnd PKG TREATMENT PLT. i.' Method of Disposal Distance to nearest: Wall Founostion 1_iL_ Property line LEACHING LINE No. 6 length of lines _ %�. --_ _ Total length/site 2 C' r FILTER dED Distance to nearest: Well 1_�s FourMetion Z2 Property Lins SEEPAGE PITS Depth Site_ _ Number SUMPS Distance to nearest: Well Foundation Property Line _ DISPOSAL PONDS 1 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 rejulations of the San Joaquin Local Health District. Home owner or licensed agent's ngnature certifMs the following:-I certify that in the performance of the work for which this permit is called,1 drab not employ any person in tach manner as to become subject to workman's rompensation kaws of California."Contractor's hiring or sub-contractli signature certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's companies- tion laws of California." The applicant m s call-W ail required rnsp45tions. Cc-rmplets drawing on reverse aide. signed +�: rule:_(,_..�'�'s. �t�-L Dats: y 12 FOR DEPARTMENT USE ONLY Application Accepted by 1-L1lY_L—11,--�'��1 Date Alp Pre or Grout Inspection by Cly _-- _ Date [ Final Inspection by Dais Additional Comments: 1 a,, i��♦L��L�r /�G V e L-r:V e -o,Ll Stk 4866781 E, ods 369-3621 / C Monte.ca 823.7104 ❑Tracy 83644 Applicant • Return an copies to, Environmental Psalth Permit/Services ISD1 E. Han hon Ave., P.O. Box 20M. Stk.,CA 95MI fit AMOUNT DUt AMOUNT REMITTED CAS,, RECEIVED ey DATE ►tfilAMT-No. INFO rw t)24 rety . ., )�'�' 00