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t111� 9a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E . HAZELTON AVE . , STOCKTON , CA Telephone (209 ) 466-6761 " PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ( Complete in Triplicate) - Application is hereby 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 District. ( Job Address g0 (if yv'A, &TFE67, h oAlr �r r7c = r City S/bChRMt Lot Size PM Owner's Name JR a �IPur➢H�NO B YA Address 1013 D ,STRd — i SSenAr,En,r� Phone 14 ) ` YY 7 .W n94�Gs Contractor & R41YPc2:!pz LJ Address 430 ,Ey0 < 09 A' -P-LMdwEZzn License No. 960bO Z. Phond` /> H7 ;6 TYPE OF WELL/ PUMP : NEW WELL N WELL REPLACEMENT ❑ DESTRUCTION ❑ V49P02 (F < v nY PUMP INSTALLATION 1-1 SYSTEM ElOTHERK) ✓APUZJftl Ucf= "" DISTANCE TO NEAREST: SEPTIC TANK _1f[ 4 SEWER LINES � DISPOSAL FLD . zt/� PROP. LINE A114 FOUNDATION ,l//A AGRICULTURE WELL a/4 OTHER WELL NIA PITS/ SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - ,r El Industrial ❑ Open Bottom ❑ Manteca Dia . o1 Well Excavation Dia. of Well Casing ❑ Domestic/ Private 0 Gravel Pack ❑ Tracy Type of Casing Y _ Specifications _ t FI Public n Other ❑ Delta Depth of Grout Seal c- Type of Grout NI _ I I Irrigation Xc.-u.+._i _ Approx. Depth I 1 Eastern Surface Seal Installed by `R � - Repair Work Done ❑ Type of Pump H . P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50' 1 Depth Filler Material ( Below 501 TYPE OF SEPTIC WORK : NEW INSTALLATION I I REPAIR / ADDITION I I DESTRUCTION I 1 ( No septic system permitted if public sewer ' available within 200 feet. ) Ins tion will serve: Residence _ Commercial _ Other Number o units: _ Number of bedrooms Character of soil to th of 3 feet: W Is depth SEPTIC TANK ❑ Ty p - - - Capacity No. Compartments - PKG . TREATMENT PLT. ❑ _ - - Method of Disposal Distance to nearest: F ion Property Line LEACHING LINE ❑ No. & Length of lin Total length/size FILTER BED ❑ Distance arest: Well Foundation ny Line SEEPAGE PITS I I Depth Size Number SUMP ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ - I hereby certify that 1 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 agent's signature certifies the following: "1 certify that in the performance o1 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 compensa- tion laws of California." - The applicant must call forall re uired inspections. Complete drawing on reverse side. - - - Signed - - Title: - f"/� o l'pcf GFrYirr, Dater � �137 cWtVll ?I } ) _. /dry FOR DEPARTMENT USE ONLY AAF A4e4Q Application Accepted by ' '" � �ld , Date- , r / 1 L / F . Area Pit or Grout Inspection, by Date , - Final ,inspection_by . Date Additional Comments: - ❑ Stk ' 466-6787 - ❑ Lodi 369-36210 Manteca 823-7109 O Tracy 835-6385 - Applicants Return all copies to: Environmental Health. Permit/Servicas. 1601_E„. Hazelton .Ave., P.Ot Box 2D09, Stir., CA 95201 - - - - FEE AMOUNT DUE AMOUNT REMITTED CASH ::RECEAtED By , DATE {: PER9NOaNFO♦ EH II31 IaEvtlx 51 , �