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111,1511,1 1,111 :119118 1i 111115, Z1i 11 R111 imam s APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E, HAZELTON AVE., STOCKTON, CA Telephone (209)466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby mads to the San Joaquin Local Health District for a permit to coristruct and/or Install the work herein described.This apprnation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No.18Q for wolf/pump and the Rulers and Regulations of the San Joaquin Local Health Diistdct. 11 !" Jac)Address 0/1' (�. 4 r- S`t C rS w - City_Lot Site PM Owner's Name.-SB ak-rr n_UR1 I Ae-C 1 e-S cCt�Address 0 h.f— Lu i!5 e Ntot..3��r(.t W�6cne ConlractorT �Lt�h .12�d M0.0C-Address1 �1�(3la�tfeA�3'#r� License Ho. Phone L/`.3L61�f3 TYPE OF WELL/PUMP: M rA; (--t+JEWW WELLWELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.LUIIE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS q ❑Industrial 0 Open Bottom 0 Manteca Ute.of Well Excavation Dia.of Weil Casing �nOomesticlPrivate ❑Gravel Pack ❑Tracy Type of Ca.; Specifications. ❑Public OPOther 0 Delta Depth of Crout Seal Type o1 Grout 4 5-4&1 6t& 0 Irrigation '�pprox.Depth ❑Eastern Surface Seal Installed by t Repair Work Done ❑ Type of Pump H.A. Stats Work Done Well Destruction 0 Well Diameter Searing Material(top 50') Depth Filler Material(Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION❑ DESTRUCTION 0 (No septic system permitted if public sewer is available within 200 feet,) Installation will serve: Residence— Comm&rctai_ Other Number of living units: Number of bedrooms ~ Character of salt to a depth of 3 feet: Water table depth SEPTIC TANK p Type/Mfg Capacity No.Compartments PKG.TREATMENT PLT.❑ Method of Dual Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No.b Length of fines Total length/size FILTER BED ❑ Distance to nearest: Well_ Foundation Property tine SEEPAGE PITS 0 Depth Size Numbor -- SUMPS 0 Distance to nearom- Well Foundation Property Line DISPOSAL PONDS 0 hereby certify that.1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws,and rules and rogu!atiorns of the San Joaquin Local Health District. ' ' Home owner or licensed agent's signature certifies the following:"fcertify thsi In the performance of the work for which this permit Is Issued,I shoe not employ any person-iri such manner as to become subject to workmim's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"1 certify that in the performance of the work for which this permit is issued,I shall employ piusons subject to workman's compensa- lion laws of California." -_ The applican must tail f Tall ra ukoLlimpactions.Complete drawing on raveaids. ,',`','_ c� signed TMe:f d�z Date: OG_ZJ " FOR DEPARTMENT USE ONLY Application Accepted by Data AreaLhr' y�� Pit or Grout Inspection by2�-/�� M 1 e�Date 7 Final Inspection by Date o Z7 46 Additional Comments: --- --..--- ---' ❑Stk--466.6781----0 Lodi-369-WI----...❑Manteca-823-7104 Tracy_835-6M ----..-._.__-- '^^� Applicant-Ratum all copies to:Environmental Health Pomwt/Services 16D1 E.Hazalton Ave., P.O.Box 2009,Stk.,CA 95201 FEE AMOUNT DUE AMOUNT REMITTED AECFJYED BY DATE PERMIYNO. INFO - CASH EH 1473