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M - APPLICATtON FOR PERMIT QAN JOAQUfN LOCAL HEALTH DIST 1601 E. HAZE i ON.AVE., STOCKTON, CA Telephone (209) 466.6781 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 andlor install the work herein described. This application fs made rn compliance with San,Joaquin County Ordinance No. 549 for sewage or No. IB62 for well/pump and the Rules and Regulations of the San Joaquin is Local Health District. i Job Address /l1,15— 4!M+UEA-- r_:k4$Wr -fAlE_ City Lot Size -V PM r '/_ Owner's Name ep !}1Pl.f✓ A"OAtp.- Address E-6- Q ©L Phone(�Vi)zel~-3-5m rues, 0/4. t'cuS/F��t� 5�9301TL5_" _ Con!racior G/�l"r3 a'Rt#+l/CsF��[Ci Address _173 �4-44-66 e—TL License No. 45�.Z6z Phone( j TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C DESTRUCTION PK PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS lNT£NDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PAYMENT L; industrial ❑ Open bottom C Manteca Dia. of Well Excavation f�f� i Domestic r private ❑ Gravel Pack ❑ Tracy Type of Casingt!Ffl � X-1 i Public f 1 Other F1 Delia Depth of Grout Seal APR 0 C� XV31 irugation Approx. Depth I I Eastern Surface Seal Installed by UNTY Repair Work Done IJ Type of Pump H.P. State Work 000613116 H Cr n CES j Well Destruction ❑ Well Diameter Sealing Material (top 501 EALIt10{yj 1t"d' Depth Filler Material (Below SO') TYPE: OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITION I f DESTRUCTION (No septics stem permitted if availablwithin 200 feet.) public sewer is Installation will serve: Residence_ Commercial T Other j Number of living units: Number of bedrooms m Character of soil to a depth of 3 feet: g Water table depth D b SEPTIC TANK ❑ Type/Mfg capacity ld4l V- No. Compartments AIA PKG. TREATMENT PLT. C1 Method of Disposal l Distance to neatest,- Well ^{ Foundation Property Line LEACHING LINE n No. 8 Length of lines Al A Total length/size i FiLTER BED O Distance to nearest: Well Foundation Property Line I I SEEPAGE PITS I I Depth Size Number SUMPS L-1 Distance to nearest: Well Foundation property Line F DISPOSAL PONDS 0 i hereby certify that I have prepared this applkation 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 Di§trict., j 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,t shall not employ any person in such nlennef as to becom6 subject to wprkman's compensation laws of California.'' Contractor's hiring or sub-contracting signature certifies the following. "I cern that in the rfortttan r A W pe t:e of the work for which this permit is issued, I shall emp(ay persons subject to workman's compr,nsa- lion laws of'California." The appfican us caIIor "ll required inspictions. Complete drawing on reverse side. Signed X Title: suziiwVtt04- Date: FOR DEPARTMENT USE ONLY —� Application Accepted by Date 4,— Area QJ Pit or Grout Inspection by Date Final Inspection bybe, Date Y Additional Comments: j u Silt 466-6781 ❑ Lodi 369-3621 ❑ Manteca 923.7164 ❑ Tracy 835-8385 Applicant - Return all copies to: Environmental Health Permit/Services )661 E. HazeItgn Ave., P.O. Box 2009, Stk., CA 95201 i $ FEE INFO AMOUNT DUE AMOUNT REMITTED C RECEIVER BY DATE PERMIT NO. - EMI7.7.iNI:V t4 •s. �.� �rV+' vJ rl. J� Orlr� - I EH .le