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FOR r MENT USE ONLY Date -- Final Inspection by ed if public sewer 15 Seis7--1 AIPP-LICATION FOR PERMIT , it1,44) - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209)(209) 466-6791 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -1 (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 Local Health District. • • Job Address p.,) f • f Ns. Is 0 C ity L zE_--t•-t Lot Size . I P\Cr--R.1 — 't !..11 ': - Owner's Name • -I- per2--1_.34- - Address- ' Phone Contractor) CE AL2k-V1kI-1-- Address 35O C icense No..3 4C0--- Phone q 415:4, all TYPE OF WEI/PUMP: NEW-WELT-Fr- : WELL-REPLACEMENT -0 'DESTRUCTION "-IH -,M311•••••••- PUMP INSTALLATION CI SYSTEM REPAIR 0 . _ OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL RD. PROP.' LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ - • -4--WPE OF WELL-4-REIDBLEM-AREA---60-48T-ROGT-ION-SPEG-IFIGATIONS----------- 1 0 Open Bottom CI Manteca Dia. of Well Excavation Dia. of Well Casing / E Gravel Pack 0 Tracy Type of Casing Specifications ; 0 Other ...0 Delta Depth of Grout Seal Type of , Grout • . .............Approx. Depth' 0 Eastern Surface Seal Installed by 1 ... Type of Pump H.P. State Work Done Well Diameter Sealing Material (top 50') ..- Depth Filler Mate'ria1.(BeloW 504 EL" Industrial ID Domestic/Private Li Public 'ID Irrigation ,k - Repair Work bone Li Well Destniction Li TYPE OF SEPTIC WORK: NEW INSTALLATION .._...FtE1PAIR/ADDITION j DESTRUCTION 0 (No septic system perrnitt available within 200 feet.) Installation will serve: Residence jomrnercial Other Number of living units: Number of bedrooms Character of soil to a depth.-of 3 feet-‘.."- C._ t• SEPTIC TANK N----Type/Mfg C y PKG. TREATMENT PLT. Li ' r-4 Distance to nearest: We)) t-ik-J Foundation .50 Property Line LEACHING LINE & Length of lines• Total length/size 3 --r-s FILTER BED \ El Distance to nearest:Foundation Property Line - • SEEPAGE PITS PITS Number 1glit SUMPS LI bitance to nearest:. Well Foundation ...property Line DISPOSAL PONDS , 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 rules and regulations of the San Joaquin Local Health District. - Home owner or licensed agent's signature cgiiifies the following: "I certifirthat in the performance of the work for which this :;ermit is issued, I shall not employ any person in such manner es to became subject 'to workman's cornpensation laws of California." Contractor's hiring or sub-contracting signature certifies the followir4 "I certify that in the performance of the work-for which this permit is issued, I shall employ persons subjecit to workman's compensa- tion laws of Californ. The applica m call to ri suired pect ns• omplete drawing o jeverse s' e. Signed Application Accepted by Pit or Grout Inspection by Additional Comments: Stk 466-6781 0 Lodi 369-3621 ID Manteca 823-7104 E Tracy 835-6385 Applicant - Return all copies to.: Environmental Health PermitiSrarvices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9:520 Title: Date - ei0 5-% 815 4 EK 13-24 (REV. / 8 5) EH 14-26 FEE INFO AMOUNT DUE AMOUNT REMITTED (3:E.1) CASH RECEIVED BY DATE ' IDERMIT NO. J 1 CZ) i Water table depth No. Compartments Method of Dispose