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APPLICATION FOR PERMIT r 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 Local Health District. Job Address. A 3 �� ' �Gt.IbTT �aI City/-OcKe10Y� Lot Size �� cr�s PM r Owner's Name /��'. Jigirf`141V Address A3 23'' /✓ �GL,le77- JJ1.1, Phone C ontractor# /9Nr1S -- Address AmZ FZ-0 wml ate' License No. yYYW' Phone SR3'yZl� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ - t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ' DISTANCE.TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f ❑ Industrial ❑ Open Bottom G] Manteca Dia. of Well Excavation ~ -Dia. of Well Casing iF LI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Sliecif'ibations {1 Public ❑ Other ❑ Delta_ .----.Depth of Grout Seal _._-Eype.of Grout ! 1 Irrigation --.,Approx. Depth t t I Eastern Surface Seal Installed by _ �J .... v 1 i Repair Work Done LJ Type of Pump � � .•H.P. State Work Done _ 'V Well Destruction ❑ Well Diameter Sealing Material (top 50,')., Depth # Filler Material IBelow 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( 1 DESTRUCTION I 1 INo septic system permitted if public sewer is M available within 200 feet.) Installation will serve: Residence Commercial_ Other Alb 6'� �fa/r•1'g i .. I Number of living units: Number of bedrooms �' r,, { "Character of soil to a depth of 3 feet: 11e �- --`-"' `�r"'—�` —`Water"tattle depth�O� "'^ f-1) f1/� _ \V SEPTIC TANK 0 Type/Mfg �Y� Gfi'ST �� I.- Cap city 1 xe>y No. Compartments PKG. TREATMENT PLT. ❑ k Method of Disposal Distance to nearest: Wel! X00 Foundation f ' r Property Line r 1 — ' LEACHING LINE R' No. & Length of3 'VO .lines ._ -T - F Total length/size ! �O r^ FILTER BED ❑ Distance to nearest: ^^ Well /4[7 Foundation R✓ Property Line SEEPAGE PITS VI Depth -Size 34 Ofd' Number -3 SUMPS Ll Distance to nearest: Well X00 r Foundation 43"+ Property Line i 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, aIre rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "!certify that in the performance of the work for which this permit is issued, I shall n employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signatu i 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." Z I The applicant mu call for all required inspections. Complete drawing on reverse side. s � Signed )C, " _— Title: Date: '�y F-7DEPARTMENTUSE ONLY / 1 �� ?i Application Accepted by Date V Area� CP) or Grout Inspection by bate Final Inspection by Date, o 71 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P,O. Box 2009, Stk., CA 95201 f FEE AMOUNT DUE A UN7 REMI1TEt) ASH RECEIVED BY DATE' PERMIT'NO. _ INFO t.EH13-24 IREV. EH 14-28 ♦ !F df