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�./ APPLICATION FOR PERMIT { -Ptz mi -ZZ—Zo SAN JOAQUIN LOCAL. HEALTH DISTRICT 1601 E. HAZEL T 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 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. /� a// �''} Job Address _ �r 2 y 0yr11 Octr✓ City—1rinto n Lot Size PM Owner's Name .I 41 4 116V 1-04 e- Address 10, �' � 12-11 /gyp2Jr ;z 0 Phone �1"5 `S7-" y CpnlraCtor WV Way ;��` CO, AddressPt�Ts;7�' Fc �r5/ii,crY q S7/License No. 8 I�3 + Phone _70'J7 '�y�4 TYPE OF WELLIPUMP: NEW WELL ❑' WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATfON C SYSTEM REPAIR Cl OTHER P rXJi� l3c/'� h DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRIJCTfON SPECIFICATION$ • Industrial O Open Bottom Manteca Did of Well Excavation rif Dia. of Well Casing ❑ Domestic/Private Cl Gravel Pack L Tracy Type of Casrnq Specifications13c/'i i'1 Public I'l Other I DClta Depth of Gruust Sedl Type of Grout Ce-7 1 I I Irngdnon ___ Approw. Depth , - Eas:vm .'aCu Sic,i Insidil d by — Repair Work Done i] Type of Pump _— + — ____.... - -�_ __. State Work Done r Well Destruction ❑ Well Diameter y� 5e.: r.a 4'a:erlal itop 501 --- Depth 2(J �_- F.'c' Y'l,cr-al i6t1U:v i�ri I _ M TYPE OF SEPTIC WORK: NEW INSTALLATION r4 I'r R 7 D:i:nr., f;�S7f;I II;TI(}N : (No scpirc system permitted it public sewer is available within 200 feet.) 6` Insrailation will serve: Residence _ Ccmmerc.,l �} Number of living units: Number of bediooi-Is O Character of sod to a depth of 3 feur . r Water table depth O SEPTIC TANK r_i Type2Mfg _ C.:; .,c :, _ No. Compartments PKG. TREATMENT PLT [-i Method of Disposal 77 Distance to nearest Properly Line LEACHING LINE No & Length of lines Tol.il lenyth/size_ FILTER BED f I Distance to nearest: t'. ,' i c•-, ,:;,t,„r _ _ Property Line SEEPAGE PITS I I Depth S,:r Nilmber - SUMPS I 1 Distance to nearest: 1'., i Fn.,n,l,T.011 __— Property Line DISPOSAL PONDS F) hereby certify that I have prepared this application and u:,: :t,- d: ;,e rlr,ne rn a Curdance with San Joaquin county ordinances, state laws, and rules and regulations of the So-, Joaquin Local Health Home owner or licensed agent's signature certihes rhe toN, I cr'i f, ;hat in the to�tfurrnance of the work for which this permit is issued, I shall not employ any person in such manner as to become sub^1 + - .,n's Cu pens,'i„n la1vs of Californ a.” Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of Vie for wh,crt this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." 5 rrk�. 'h G/Cc-L)` ,!�vt O"o S The applicant must call f atl r quired inspections. complete ora.�.na on reverse s d r eoel A/2? Signed XLL T,;'e- � - C/e Date: , FOR DEPARTMENT USE ONLY Application Accepted by _- Date Pit or Grout Inspection by _ Dwe _ Final Inspection by a - Additional Comments: se�kI� 1-� 5l I C� ❑ Stk 466.6781 ❑ Lodi 369-3621 L3 Manteca 823 71 G; y 1135 S Applicant - Return all copies to: Environmental Health Permit.Serv,ces '501 E Hazelton Ave., P.O. Box 2009, Sik., CA 95201 INFO FEE AMOUNT DUE AMOUNT REYiTllED CK HECOVED BY DATE PERMIT'NO. . EH 13.24 rFiEv-, y, 7C�f Ii✓�- O p Ut (] -- ! V• EH 1670 LJ j L'�