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R� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Teleptlohe (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address Y V...=) e 7? 9 City eo_�O� Lot Size ZdAl:!�-_ PM Owner's Name Ze Address ,9,4 r2q Phone 2- Contractor VLA- 7 Address e5^7- License No.30 Phone Kim TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 El Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i M Public F1 Other F1 Delta Depth of Grout Seal Type of Grout __ �n I I Irrigation --Approx. Depth I 1 Eastern Surface Sedl Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ElWell Diameter Sealing Material {top 501 r Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet./ Installation will serve: Residence Commercial_ Other Number of living units: __L Number of.b drooms Character of soil to a depth of 3 feet: *-- Water table depth R1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ j Method of Disposal Distance to nearest: Well i+ Foundation Property Line LEACHING LINE El*'-No. & Length of lines es Total length/size i FILTER BED ❑ Distance to nearest: -7 Well Foundation S o + Property Line. dU> N SEEPAGE PITS ilei/Depth � Size Number SUMPS' Ll Distance to nears§t`-""""t7t/el! DISPOSAL PONDS Cl �v= Foundation .� �✓ Property_ � Line ___ N I hereby certify that I have prepared this application and that the woik will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of-the San Joaquin Local Health Distr/i'�Ct --.rn'i" Nome owner or licensed,agent's signature certifies the follocertify that in the performa\e of the work for which;his permit is issued, I shall not employ any person in such manner a§-fo becomesutiject to., n's compensation laws of California,."Contractor's hiring or sub-contracting signature certifies,the following: "!certify t-6at in the perfomrtante"bf ii:vi k ffor which this permitii issoed,.l°shai employ persons subject to workman's compensa- tion laws of California., 1,441 i The applicant-must call for all r uired inspecticing Gompletri-dlrawing on reverse side. `� r Signed X t 'Title: Date: FOR DEPARTMENT USE ONLY I „. Application Accepted by Date 2 Area Pit or Grout Inspection byDate Final inspection by Date 1U3d_8"r Additio{tal Comments; ❑ Stk^�466 8989”-^�C Lodi--369 3621-----'E}hAarlte>s-823 X104 „-B Tracy-835 63$5-`-'------- Applicant - Return all copies to: Environmental wealth Permit/Services-' 607 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. +,EH13211REV.i/x51 EH 11-2e 7 .d (3 fJ[!� / � , �`y, Q 00 —YI CCU11