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APPLICATION FOR PER k a SAN JOAQUIN LOCAL HEALTH DISTRICT ji 1601 E., HAZEI`TON AVE., STOCKTON, CA Ur J Telephone (209) 466-6781 I� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j' (Complete in Triplicate) Application is hereby made to the San Joaquin Locali Health District fora F; made H compliance with San Joaquin County Ordina'ncelNo. 549 for sewage or No. 1862 for weft/pump and the Rules and Regulations of the San Joaquin permit to construct and/or install the work herein described. This application is Local Health District. 'I Job Address ' - u FCetha•Z i I+ Sr E Ciry T�A1_r00 I; Lot Size 1,00Z.(..Jl�� PM Owner's Name tr.\/IZZ_ } ` I U J�� Address ij Phon 5 Contract f�? 3 i � �' E1` 3 ' i�Address >CL`�k , �n'? l�c•ucr� �`IS) TYPE OF WELL/PUMP: '�Icense No. `i3�i3 Phont� I� 01 231,1 n\1� iI' jl NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ \`p PUMP,INSTALLATION O I ii SYSTEM REPAIR ❑ OTHER C$.�{ DISTANCE TO NEAREST: SEPTIC TANK '' 1.SEWER LINES �� r-�rz+:r-,•�� t�t..�� —�� DISPOSAL FLD. PROP. LINE FOUNDATION , AGRICULTURE WELL OTHER WELL I PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia, df Welt Excavation +y bio. of Well Casing �ti�—__ I ❑ Domestic/Private Gravel Pack ❑ Tracy Type YPe of Casing— _ Specifications ' F� ❑ Other ❑ Delta :i Depth'of Grout Seal _3t��=`{ El Irrigation C-_L,pprox. Depth ❑ Eastern Type of Grout =rn i Surface Seal Installed Repair Work Done C1 Type' of'Pump H.P. Well Destruction ❑ WOII Diameter " State Work bone_ Sealing Material;ftop 50•) ►�tou.�oa•x� Depth .;i{ ; Filler'Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION LJ REPAIR/ADDITION L]! DESTRUCTION F1 (No septic stem; i P Y permitted if public sower is Installation will serve: Residence :1 available within 200 feet.) i Commercial Other Number of livingunits: " �' Number of bedroorris Character of soil to a depth of 3 feet: i Water table depth ' SEPTIC TANK ❑ Type/Mfg Ce act PKG. TREATMENT PLT. ❑ Capacity— No.'!Compartments 13 li Method Of Disposal Distance to nearest: Well Foundation Property Line 4 LEACHING LINE Q No. 1f, Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation h Property Line Ik SEEPAGE PITS ❑ Depth Size 4 SUMPS Number ❑ Distance to nearest: WeNFoundation Property Line DISPOSAL PONDS ❑ i .I :i ` at the work will be done in accordance with San Joaquin county ordinances, state jaws, and I hereby certify that I have prepared this application and th rules and regulations of the San'Joaquin Local Health District. c; Home owner or licensed agent's signature certifies the following: employ an g: "I certify that-in the performance of the work}or whicti{this permit is issued, 1 shall not - Y y person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ tion laws of California." P Y persons subject to workman's compensa- tion The applicaqqr.st call for 'fl re ui inspections. Complete drawing on reverse side. f1 I geN I Sind Tftle: �c +�L�Y r5% l t]ite: D ONLY Application Accepted b DateArea Z- /1-0 In Pit r Grout f s ti y D toFinalpection by Dateln _2-8�_. � Additional Comments: I QSflc 466-6701 ❑ L i '369. 1 ❑ Manteca 823.7104 C] Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk•, CA1 :1 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO g CASH ;- RECEIVED BY DATE PERMIT'NO. • EH 1314(REV:i •.i y - ' - fH I4.16 v�/IL�..� 7