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i 14 APPLICATION FOR PERMIT .� SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (200) 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED (Complete in Triplicate) Appliicadon is hereby mode to time San Joaquin Local Health District for a Permit to construct and/or Install the work herein described.This application is mads 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 Addreq 464R Fant Varezlo6 Road City vt-eelteift Lot Sim PM Owner'i Name --May 1A) we Prnpe t1AA Address P.LLBQY- 2a 2 - — Phone 415 457 2351 Contractor ' a Address L.Icen3e No, Phone • loran' �81J84Z--- TYPE OF WELL/PUIWP NEW WELL WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK S SEWER LINES $Q ;= DISPOSAL FLO.A PROP. LINE 4-2&t_ FOUNDATION 5' AGRICULTURE WELL OTHER WELL �. PITS/St MPS A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial © Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing 2 r' ❑Domestic/Private M caravel Pack ❑ Tracy Type of Casing B32C _ SpecifiCaltions A20 11 Public ❑Other F1 Delta Depth of Grout Seal 25 Type of GroutCemenJ�be e I I Irrigation —Approx. Depth I I Eastern Surface Seat Installed by. Datum Extiloration Repair Work Date ❑ Type of Pump H.P. State Work Done _ ell ❑ Well Diameter Seating Material Itop 50'I Depth Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION [A DESTRUCTION I I INo septic system permitted it pudic available within 200 feet.) kgUNorion will serve: Residence_ Commercial Other Number of riving units: Number of bedrooms Character of soil to a depth 6f 3 Teat: Water table depth SEPTIC TANK 0 Type/Mfg Capacity _ No. Compartments PKG.TREATMENT PLT.❑ Method of Disposal Distance to neatest: Well Foundat'ron Property.Line LEACHING LINE ❑ No.A Length of lines Total length/arcs FILTER BED 0 Distance to nearest: '. Wall Foundation Property Line SEEPAGE PITS ['I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DiSPQSAf.PONDS -0 �,.w.+...• ._..._ �-:, — I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws..and nmles and mipAitions of the San Joaquin Local Health Dibtrict. Home owner or Soaneed agent's signature certifies the following: "I certify that in the performance of the work for which this permit Is issued,I shell not employ any person in sues manner as to become subject to workmen's compensation laws of California."Contractors hiring or sub-contracting signature certifies the fallowing:"ll certify that in the performance of the work for which this permit is issued,i shall employ persons subject to workman's eomperrsa- - tion laws of Camornis", The appRcartt required inspections. ate drawing an reverse side. Signed TkIs: ,AllOr L� I /,3 Date: PO FOR DEPARTMENT USE ONLY / w Application Accepted by Date E Y Area Pit -pw Ion by d Final Inspection by Date Additional CanAmertq: O Stk 486-OM © Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 836-6396 Appkwd-Return all copies to: Environmental Health Permit/Sewiees 1601 E. Hazelton Ave., P.O. Boot 2M, Stk., CA 96201 E AMOUkT DUE AMOUNT REMITTED K H RECEIVED BY DATE RERMT NO. INFO . t atev.,,.ter 35 0 r33`� 7- 7- P�=