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> r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (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. 1862 for well/pump and the Rules and Regulations of the San Joaquin 4q Local Health District. y€ Job Address AW Z-f-A 15, C`r1TChc7, City_�y'IyG�/� Lot Size Af4'ch PM Owner's Name M,91v(/A L /res Address F� �•4 � Phone .k __ . Gantrattor T � ��' Address �� '-`License No"' �y P� �`w 'c TYPE OF WELL/t4Mt; NEW WELL L1 IZWELL REPLACEMENT ❑ DESTRUCTION ❑ ..ti_,�..—_-x.,-..ca..-n-��u:•,cup,rr:..__r,..sc:sv.w,.,.:..:wr-s�,s:v.�aa.r_s,w:aar..nww�+.•mry PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCETO NEAREST: SEPTIC TANK r SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA„,, CONSTRUCTION SPECIFICATIONS ❑'Industrials'- - -Q Open $ottom-s—--•❑=Manteca--'--x=-;€Dia:-of-Well Excavation --------Dia:of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ( 1 Delta Depth of Grout Seal Type of Grout _ I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H P C"h! State Work Done Well Destruction ❑"`1Ale` Diameter-"-'7 `Sealing Material Atop 50► _,._ —____.____ Depth Filler Material (Below 501 TYPE.OF SEPTIC WORK: NEW•INSTALLA'TION-' =REPAIR7ADL)ITIONt-1-1•'”`[)ESTRUCTION`:l'I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms, Character of soil to a depth of 3 feet: /4 Do L t" r Water table depth 70 SEPTIC TANK L1, Type/Mfg aj'e Ge43'r Capacity -10e7, No. Compartments �+ PKG. TREATMENT PLT. ❑} Method of Disposal Distance to nearest: Well Foundation f-� f Property Line LEACHING LINE..,. Ply No- & Length of lines 3- Total length/size -Too FILTER BED �,, ., ❑ Distance to nearest:w_ Well Foundation �� Property Line •�� 1 - - t SEEPAGE PITS l I\ Depth Size Number SUMPS 0 -DistanceAto nears t: Well_ Foundation Property Line { DISPOSAL PONDS ❑ 5 hereby certify that I have prepared thisrapplicatiori•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 Diltrict. -'' -�---.•_ _ 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, shall6t1 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 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 comper;s-Y r-l",` tion laws of California The applicant mut call for all required inspections. Complete drawing on reverse side. Signed X A Title: Date: 9-/--S'9 � FOR QEPARTMENT USE ONLY Application Accepted by Date Area -� Pit or Grout Inspection by Date F II pection by ff) Date ; Additional Comments: ❑ 5tk 466-6781 ❑ Lodi 369-3621> ❑ Manteca 823-71 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 • .tiba I (FEE AMOUNT DUEAMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ♦.EH 13-241REV.i/x51 V-00 �t/• vo g7n Q-sfy VALAIr v EH 14-28 '7 1