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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) .466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 1 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 3 S W f}S I�iIN G 1�n1 372 �1 City_.S 76C 1<1 0A1 Lot Size PM � 4 ff// r . Owner's Name 1� r co Address 1010 s C PLN t^p I Phone Cont{actor.EX j' 14 _Address y I S _ .-5•! - �Zme N1.q Phone C �. y fv5 TYPE OF WELL/PUMP: NEW WELL ❑ WELL-REPLA EMENT�(7 ``DESTRUCTION L1 _11�^IPO1`-7 vv C r PUMP INSTALLATION ❑ f SYSTEM REPAIR ❑ OTHER ppj,r)J C3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ;DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL !OTHER WELL SPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREAkt +'CONSTR CTION SPECIFICATIONS ✓ } J1 , 11 Industrial D Open Bottom ❑ Manteca Dia. of W II Excavation CfO!row-_*_-_;A. Dia. of Well Casing, * ❑ / j . DomesticlPrivate LI Gravel Pack ❑ Tracy Type'offC sing PV t f the N�,-- Specifications 7 I i Public y -[-I Ot v „C f-1 Delta Depth of ut Seal /VM Type of{Groull'A e } XI IraltV t�r1O "lfltrox. Depth I 1 Eastern t Surface S a_l'lnstalleedd by / y1/{j y ep rr Wo k Dane f._] Type of Pump H.P. _ State Work Done Z IT Well Destruction 1_1 Well Diameter " Sealing.Material (top 501 'y Depth / Filler Nadal (Belovy 501 TYPE OF SEPTIC RK: NEW INSTALLATION 1.1 REPAIR/ADDITION',l I FSTRUCTION 1 o septic system permitted if public sewer is 4 available within 200 feet.) Installation will serve: sidence— Commercial Other_\. Number of living units: Number of bedroomst4"L f ! Zta� Character of soil to a depth pfeet: Wate depth SEPTIC TANK ❑ Type/ fg Ca aCity Np.'Compartments PKG. TREATMENT PLT. F-1 jf r Method of Disposal r Distance to n est: Fo,Lati n ' Property Line LEACHING LINE is No. & Length of - es l Total length/size d FILTER BED t I Distance to earest: Founda ion /.Property Line SEEPAGE PITS it I t D th Size Numberfl SUMPS I 1 Distance to nearest: Well - FO alion / Property Line DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will'be dor a in accordance with San Joaquin.;counly ordinances, State laws, and rules and ragulauuris of the. San Joaquin Local Health District { Home owner or licensed agent's signature certifies the following: "I certify that in he performance of the work for which this permit is issued, I Ohall not employ any person in.such mms manner as En hacooubiect to workman's compensat on laws of California." Contractor's hiring or sub-contracting signature certifies the following:°�I'`cenity that in the performance of the work for which this permit is issued, !shall employ persons subiect to workman's cornpensa. tion laws of California, The applicant must call jor all-requrred inspections. Complete drawing on reverse ide. Signed X P n t c2�Ff � 4 /Title: rn LG4 `o D! —.... ��- ff�f 1Ip ate: Yl�FORDEPAR'CME �i SE ONLY' COMP ra y Application Accepted by Date �`~ Area F. i Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: D Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 IJ Tracy .835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEE rl INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE �j PERMIT'NO. r EH 13-Z4/REV.lIK51 EH 11-76