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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT f x 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. 1862 for well,pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �� ' G oy.>wL HoUvw Rel City G Lot Size d&70 46YGrs PM r Nf T T G ~1/ve,o, LL � Address -.�. ry , ,. ^ Po --�^--Owner's-Name.-W ; - - Phone ._ .. � Contractor I)AtrISewIf f0/Y 'Address 4604-� 111-V to V A,1 License No. 00�89l Phone TYPE OF WELL/PUMP:.. NEW WELL ❑ WELL RE15LACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ t '`: SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ' PROP. LINE ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i d INTENDED USE TYPE OF WELL_ - PROBLEM.AREA CONSTRUCTION SPECIFICATIONS C ❑ Industrial t ❑ Open Bottom © Manteca F'k Dia. of W611.6cavation Dia. of Well Casing r Cl Domestic/Private ❑ Graval Pack ❑ Tracy ., Type of Casing Specifications F1 Public y' f_l'Other n'Delta _ Depth of Grout Seal Type of Grout r K. I I I Irrigation - . .4��.-Approx, Depth l 1 Eastern "� � Surface Seal Installed by _ Repair Work'Done ❑' Type of Pump H.P.-r-»- State Work Done a Well Destruction ❑ Well Diameter Sealing Material {top 50') Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION OT REPAIR/ADDITION t I DESTRUCTION {,I (No septic system permitted if public sewer is 4 t available within 200 feet.) Installation will serve: Residence_ Commercial— Other � Number oflivin f ,. g units: � Number of bedrooms � Character of soil to a depth of 3 feet: -:%'A AldY Water table depth SEPTIC TANK pf" Type/fUlfg / t° &,4 /Y c, Capacity �t�fl No. Compartments iL PKG. TREATMENT PLT. ❑ ' `. Method of Disposal h Distance to nearest: Well -4 Foundation r 16` Property Line R LEACHING'LI E- . ZZ No7&•Length of lines 9p r. Total length/size f �O I FILTER BED ❑ Distance to nearest:' Well -9 'f�fr°• Foundation- jd Property Line ( SEEPAGE PITS i 1 Depth 1 Size I Number SUMPS Ll' Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t ' 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 3 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 t 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." The applicant must call for all required inspections Complete drawing on reverse side. I Signed X i Title: Date. ' j - r 7 FOR DEPARTMENT USE ONLY y 16 Application Accepted by y Date Area r Pit or Grout Inspection by s Date Final Inspection by Date . " Additional Comments: �/ IV0 /"'� `�� - /�'�- rG" f�Kr I �rU��/�/.t//H+� {T/�9►Zl�l ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services.1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO + EH 13-24(REV.1/y 51log Q D 3 EH 14-28 - ff -/Li L>'—S �U] 4 - k t '