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APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA k Telephone (209) 466-6781 r + 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. ..r t c t/If - j S -2-4? t . Job Address 0 Lot Size /;�--' 'PM Owner's Name _ �� '' Address Phone .r Z � Q Contractor_ {t UN Address License No. dYSr Ph SC.S TYPE OF WELL/PUMP: NEW WELL ❑ WELL. REPLA EMENT ❑ DESTRUCTION ❑ A-CL7j"TIOT4 SYSTEM-REPAIR-EIS-- -OTHER ❑ li DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE "`•ii>i FOUNDATION�Y ��AGRIGU.L7UFiE.WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE-or-WELL_PR 0BLEM ARBA CDNST UC ION SPECIFICATIONS rC) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f ❑ Domestic/Private ❑ Gravel Pack Cl Tracy Type of Casing Specifications kFI Public !_1 Other `' F1 Delta Depth of Grout Seal Type of Grout I I Irrigation _.-Approx. Depth I 1 Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H,P, State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50-i" '`` "" CI i Depth Filler.iVlaterial (Below 50') - r TYPE OF SEPTIC WORK: NEW INSTALLA ION I;l, REPAIR/ADDITION DESTRUCTION.1]-INo septic system permitted if public sewer is i _ "-a0ailable within 200 feet.) +. + Installation will serve: Residence _ Commercial' Other j Number of living units: Numberfof bedrooms l - �' X �m / # Character of soil to a-d6pth of 3 feet: •' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PELT. ❑ p Method--ot Disposal • j* l?D' tance to nearest: Well . Foundation Property.Lineg• LEAG41NG LINE ❑i No. & Length of lines 1401f^ ; Total length/size 1 DA I FILTER BED E1 Distance to ear t: well'• f -Foundation Q Property Line +GF SEEPAGE PITS VI Depth I 1 4 1F Number rf!�`,_' S ra f ^e SUMPS Li Distance to nearest: Well F u' ationProperty Line_ +de DISPOSAL PONDS Q l��r"2' f �lr} Oaf✓' Ctr v �i. ) F n s.4 3Y I hereby certify t'hatrlahav spared this application and.that the work will bQ;n j n� in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. : I '' ) Home 3wner or licensed a�t's signature certifies the following: "I ceftify thOn the performance of the work for which this permit is issued,.•/ shall not I employ any person in such Imanner as to become subject to workman's c6pehsation 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,1 shall employ persons subject to workman's compensa- tion'laws of Califofnia." '• *yrs l` 4 r The applicant must call foq 11 required instions. Complete drawing—on-reverse side. Signed X.- ' { � Title: T� ____1 Date: FOR DEPARTMENTCLIS'E ONLY F Application Accepted byet Date`` ` S Area Z iPii� r'Grobt Inspection by Date x 4Final Inspe�tjbn by-A�rn ^ -- Date Additional Comments: f ; y ❑-Stk 4`66-6781 i ID-EW 369-362.1. OJ,Manteca 623-71 ` •04'' ❑ Tl'acy 635-6385 Applicant?-IReti rn ajl,copies to: Environmental Health 'Permit/Services 1601 E. HazeltaAve.,4'.0' Box,2009, Stk., CA 95201 y I S§= z FEE AMDUNT DUE AMO IJ{ tMITTED CASH E ~RECEIVED BY �'OATE /PERMIT'NO. (NFO a.Et{1324 IREV.i/K 51 " EH 14-26 sy 'a '";�"� s • t:?