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�G�taKT Seoc� 'I APPLICATION FOR PERMIT 4J eATh V14 N" SAN JOAQUIN LOCAL HEALTH DISTRICT O fOD i 1601 E. HAZELTON AVE., STOCKTON, CA �J 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 i Local Health District. AlLQ Job Address I /PI/ I j 70 Al ✓�a. V i S City t Lot Size I�� PM Owner's Name r ` I r' an I31A Li�-�Address Phone v a Contractor v`�.. frOS.5t�S0+1 _ Address 7 2 S LC.n�St�T J01 License No.&3Q C?1 Phone 7Ys ".2227 TYPE OF WELL/PUMP: NEW WEL / WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION Q' `SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK Meelk SEWER LINES DISPOSAL FLD. PROP. LINE 1110'16f- - FOUNDATIONS AGRICULTURE WELL-3Wg�_---OTHER WELL•�=-PITS•lSUMPS — - INTENDED USE TY E OF VALL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ft ❑-In strial�: Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ilWomestic/Private t ❑ Gravel Pack ❑ Tracy Type bf Casing STAeL Specification's " n Public. Ll Other h ❑ Delta Depth of Grout Seal a!BP�� Type of Grout J I I Irrigation /-.-Approx. Depth l I Eastern Surf ce Seal Installed by Repair Work Done ❑ Type of Pump"tiSL(l -- H,P. State Work Dorie_ Well Destruction �❑ Well Diameter Sealing Material (top 501 i Depth, Filler Material 16elow 50') TYPEOF.SEPTIC WORK NEW..INST-AL-LATION-1 1 REP AIR/ADDITION I I DESTRUCTION [.I (No septic system permitted if public sewer is -Z ' available within 200 feet.) Installation will serve Resid73fee CommercialOtherNumber of 41, units: m of bedroomsCharacter of soil to a depth t: - Water table d�e-ptthh~ _-- SEPTIC TANK" ❑ 'Type/Mfg Capacity -C pYSI�i artments J .PKG. TREATMENT PLT. ❑ : r Method of Disposal Distance to nearest; Well F ion Property Line i rC v! r LEACHING UNE ❑ No. &'•L'ength of line gia_I length/size FILTER BED ❑ Distance t rest: Well Foundation Properly Line SEEPAGE PITS + Depth 1 Size _ Number SUMPS ❑ Distance-to nearest: Well Foundation Property Line " DISPOSAL PONDS ❑ t 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 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 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." Theapplicant must II for all requir d inspec ions. Complete drawing on reverse side. i F`? Signed -Title: Date: "5-- l tS FOR DEPARTMENT USE ONLY Application Accepted by _.._ Date Area Pit or Grout Inspection by Date Final Inspection by Date 1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 e 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 K9 RECEIVED BY DATE PERMIT`NO. 4,EH13241REV.riN51 f 4S V`� t ✓✓ �' V �/ ��4 EH 14.26