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Date: .1,V Area /5 Date,-3 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 heieby 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. y Job Address a2 J/ s e Pd City 7-;1e* r Lot Size PM - ..- Owner's Name/9. 0 ,1 --efiree-Vie-- C.--4-r-A.e.le55 SGr--7-Y-L-4-. Phone , - Con tractor Address .././??L: License No. Phone .. _ TYPE OF WELL71106.4 NEW WELL ii " WELL REPLACEMENT 0 DESTRUCTION 0 PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER C 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 CONSTRUCTION SPECIFICATIONS - Niks:. D Industrial LJ Open Bottom 0 Manteca Dia. of Well Excavation' Dia. of Well Casing El Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications 11 Public CI Other 0 Delta Depth of Grout Seal Type of Grout I I Irrigation __2Approx. Depth I- I Eastern -Sli/rfaCe-Seal- installed by------ -- • Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material (top 50'1 Depth Filler Material lBejsw 501-.-- — TYPE OF SEPTIC WORK: NEW INSTALLATION 1,1 .REPAIRIADDITION)< DESTRUCTION 1 1 (No septic system permitted if public sewer is available within 200 feet.) 1 Installation will serve: Residence IV- Commercial Other Number of living units: I Number of bedrooms •••S , Character of soil to a depth of 3 feet: ..nrainoompasig. Water table depth P "'- SEPTIC TANK C Type/ Mfg Capacity No. Compartments PKG. TREATMENT PIT. a Method of Disposal Distance to nearest: Wet Foundati.Cin Property Line .- - , LEACH/NG LINE El No. & Length of lines . , I R2 -------"k---1 Total length/size t 5-r 70 - ...71,-4, -... 2 „,„. _, ,r-ILTER BED CD Distance to nearest: Well — - —Foundation ...— -- — 'Property Line / SEEPAGE PITS I I Depth Size i • Number SUMPS Cl Distance to nearest: Wet d';', Foundation Property Line )1SPOSAL PONDS 0 ,....- z,-,• . hereby r.ertih, that I h... ......,,,,...--. .6..:- ......_.:__-,__ . pfeI,ouuIi anu [net me won e done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health DI-Strict. Home owner or licensed egent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not .employ any person instil* manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "ftyWify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa-tion laws of California. The applicant must call for at required inspections Complete drawing on reverse side. Signed X ...,4--.1/icer- _ Title: FOR DEPARTMENT USE ONLY FEE INFO AMOUNT DUE AMOUNT REmirrto assfii RECEIVED BY DATE PER MIT' NG. -70 w <5) -70/ -0-F ce176 _....,‘2` 2-22-e? Pit or rout Inspection by : Date , Additional Commems: 0 Stk 466-6781 0 L 369-301 0 Manteca 823-7104 El, Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazetton Ave., P.O. Box 2009, Stk., CA 95201 Application Accepted by Date Final Inspection by * EH t3-24 MEV., tdA EH 14.2E