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X16 (_ le I%- I 3 APPLICA7`PN FOR PERMIT 3 I SAN JOAQUIN dCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE ,STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t (Complete in Triplicate) a 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 Nn.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address I bl ( 1�©N _ � i!� R �� r City Lot Size� PM e�L�. A e S /Sl l�J• �Pow -RI Old S8 Owner's Name # Phone ' ;,' � �'TSN l s t�..,es aK� ,y ,•,f/�� Contractor's Name icense No. C)P"7 �.5 Phone a -*�'7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ �.* SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK '" `` SEWER LINES A t DISPOSAL FL_D. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL ' �- PITS/SUMPS y INTENDED USE� koTYPE.OF WELL '"-w PROBLEM AREA. CONSTRUCTION SPECIFICATIONS ❑Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing as ❑ Domestic/Private ❑ Gravel Pack #❑ Tracy Type of Casing Specifications ❑ Public ❑ Other } Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done' ❑ Type of Pumps 'T I" - H.P. State Work Done Well Destruction 'Cl- Well Diameter tT ,;Sealing Material atop 50') Depth 1 # Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is �avSu'Ipble wi�iin 200 feet./ Installation will serve: Residence Commercial Other F!� f �, t Number of living units: Number of bedrooms ' 1 $ f �� MO�� ✓� � _ Character of soil to a depth of 3 feet: ) ' N -, Water table depth ? SEPTIC TANK ❑ T r ype/Mfg Capacity o. Compartments PKG.,,TREATMENT PLT. ❑ �• ' Method of Disposal Distance to nearest: Well / ,�y� Foundation P`ro ert Line *��,. �- `r P Y LEACHING LINE No. & Length of lines N' Total length/size ' FILTER BED- ❑ Distance to nearest: Well Foundations • Property Line 't ' . 1 It ,1 SEEPAGE PITS ❑ Depth* Size ` Number SUMPS ❑ Distance 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. r-. agent's si nature certifies the followin ' Home owner or licensed a g g g: "I certify that-.in the performance sof the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's oompensation laws of California."Contractor's hiring or sub-contracting signature ' certifies the following:"I certify 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."t ' -% r 0 . � Thea nt mus all for required ' ctio . Completed win re id��]'�� `r WS-LIP .� �/ Signe 7 "r �►'RSt F+�Iwr 3 a g Title: r >* r Date: FOR DEPARTMENT USE ONLY / Application Accepted by % '02, O - Date Area 13 iPit or Grout Inspectionby _ Date Fina Inspection by -�- Date 1 �i 4J�.fi i .. Additional Comments. 5 �^^� Qhen f ❑ Stk 4664781 ❑ Lodi 369-3V1 ❑ Manteca 823-7104 ❑ Tracy 835-6386 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. + EH 13-24(REV.10/83) YT"� N 0 EH 1426 !t 6{ 1