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. !APPLICATION FOR, PERMIT SAN JOAQUIN LOCAL HEALTH [DISTRICT ' 1601 'E. HAZEL T ON AVE., STOCKTON, CA - telephone (2W 466-6781. '"PERMIT EXPIRES,' YEAR.FROM DATE ISSUED tekt(Cornplete in Triplicate); Application is hereby made to the Sari Joaquin Local Health.District for a permit to construct and/or install the work hereln described. This application is made in compliance with San Joaquin'.Cdunty Ordinance`No.549-for sewage or-No.51862 for well/pump and the Ruies and Regulations of the San Joaquin Local Health District. ZO A Job Address 061 7?�L GGl Gl City STc>Gh'ZW Lot Size. PM Ph Owners Nae -. .� -�R� ��Y/9! - --- -.----.Address--- ir+.0 /� _ ; } O one S:Z "6✓ m Contractor's Name AN ems+' ' -e 50401 _ License NoyYy�� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ `PUMP INSTALLATION ❑ '; SYSTEM REPAIR © OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK :M SEWER LINES DISPOSAL FLD. PROP. LINE {_. FOUNDATION; AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL `PROBLEM AREA CONSTRUCTIPN SPECIF_!CATIONS ❑ IndustrialT ❑ Open Bottom ❑ Manteca Dia. of Vllelf�,&cavation Dia. of Well Casing ❑ Domestic/Private C1 Gravel Pack Q.Tracyxu�' s X Type of Casinp g 5 ecifications �., ❑ Public ❑'Other ,nf] Delta Deptfik2�Grout Seal Type of Grout ❑ Irrigation f%Approx. Depth-'❑ Eastern Surface-Seal'Installed by { Repair Work Done OLS Type.of'Pump, H.P. State Work Done 4 el!• WDestr!ctlon— �V�lell Diameter' Sealing Materialr(top 50',)` i r Depth Mat pial f lelow-507 TYPE OF SEPTIC WORK � EW'INSTALLATION ❑ REPAIR'/ADDITION'IC DESTRUCTION ❑ Mo septic system permitted if public sewer is a - available within 200 feet.) �- Installation will serve:—,Residence— Commercial. X -Other Number of.living uriits:`•• - Number of bedroom's , Character of soil to a depth of 3'-feet: r Water!table depth SEPTIC TANK D Type/Mfg # Capacity No. Compartments { PKG. TREATMENT PLT D r # Method of Disposal �/ ' Distance to nearest: Well Foundation Property Line 4f LEACHING LINE`• J� rVo:'x& Length of lines ✓ "" ✓pa _ Total length/size /9� y FILTER BED `❑ YDance tonearest: Well_-r-=-- Founda'tion ✓0-1 Property-gines� _ . SEEPAGE PITS De th ,Z-5" � 33" r � i � p .Size Number F. 'SUMPS. 15.tmstance tonearest: Well - Foundation /o� Property Line DISPOSAL PONDS fl I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances`y state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent'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 in such manner as to become subject to workman's compensation laws of California."Contractor's hiring.or sub-contracting signature certifies th41following:"I,certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's be Mpensa- tion laws o(f California." { i The appliba�lt mu ,call for all required inspections. Complete drawing on reverse side. F I Signed Xs f _ �� Title: Date: p-S�SSS r iM1 _ A� el FOR DEPARTMENT USE ONLY / 0 GApplication Accepted by Date � Area l2Pit ar Grout Inspection faDate Final inspection by �- DateAdditional Comments: ia /JC h ,! r t El Stk 466-6781 ❑-Lodi 369-WI ❑ Manteca 823-7104 i ❑Tracy 835.6385 V Applicant'- Return all copies to: Erivirorimental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,Stk., CA 95201, M. FEE- __Y CK i INFO AMOUNT bur." 'AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•`NO. + EH 13-24(REV,10183) EH 1426,