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APPLICATION;FOR'P AMIT T SAN JOAO,UIN"LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone 12091 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 construdt 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 f Local Health District. CIlJ ! %Job Address S� �C ( City Cly}/�1 Lot Size 62! Yh4c PM x _ Owner's Name 1 l A!S� C.. Y t `}4lL�dress Contractorr f Ilya Address 3o Y/ X 6 31W3 13� F� License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ " "DESTRUCTIONr� r` PUMP'INSTALLATION'❑ --SYSTEM-REPAIR ❑' ""`` .° OTHER ❑- " i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE-" .I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ° INTENDED USE TYPE OF WELL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS i t ❑ Industrial D Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing 1; ❑ Domestic/Privatd. 1❑ Gravel Pack ❑'Tracy Type of Casing Specifications, ❑ Public ❑ Other ❑,Delta Depth of Grout Seal Type of Grout D Irrigation ' _Approx. Depth D Eastern Surfac"e Seai Installed by ' °` a Repair Work Done ❑ Type of Pump H.P. State Work pone 1 Well Destruction LJ 1,Well Diameter Sealing Material {top 501 I 6 Depth Filler Material {Below 501 f i ''f TYPE OF SEPTIC WORK: NEW INSTAL TION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if'public sewer is ` i t availablewithin200 feet.! I I Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: ! e Lr'tabl,depth ✓ SEPTIC TANK D r]Type/Mfg 66m - I" 7-t, l/�yx7� ''Capacity_- NoCompartments 4 PKG. TREATMENT PLT. ❑ Method of,Disposal h } Distancetonearest: Well Foundation` ! \Propertp 91 Line J LEACHING LINE'. ff rNo. & Length of lines ' 'T6Fil length/size 1 hFiLTER BED O Distance to nearest: Well�5� , Foundation�Q_-�=. Property Line �Q mow.:: :� $, - F � r .,4- � ► ��. . k FY A SEEPAGE PITS ` [4- Depth G 5 v _ Size" Number a SUMPS�X t`'= Q Distance to nearest. Well S , Foundation oaf. EProperty Line t DISPOSAL PONDS ❑ 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 i ,rules and regulations of the San Joaquin Local.Health Districi.l l Home'ow' ner or licensed agent's signature certifies thd,following: "I'certrfy[hat in the performance of the'work for which this permit is issued,.{shall not employ any person in such manner as to become subject to workmen's compensation laws of California."Contractor's hiring or subcontracting signature ( certifies the following:"I certify that in the performance of the work far which this permit rs issued, I shall employ persons subject to workman's compensa- tion laws of California. 4t !I The applicant must call for, II requir ns P"tion§ Co late drawing-din reverse'side".'., $ Signed1 f .� Title: �Q.u1 kL�f Dater 1'�` / 4• V�FOR DEPARTMENT USE ONLY i ". 45 Application:Accept9dby Date Are1/1 5X7a r Pit or Grout Inspection byl_ A' Date LL Final Inspection by l Date Additional Comments: ,,,,, El Stk 466-6781 0-,Lodi ,369-3621 . ❑ Manteca r 8M-7104— ❑Tracy „835-63$.5....._. .� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. HOelton Ave., P.O. Box 2009, Stk., CA 95201 FEE ✓ INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT N0. + EH13-24 fREY.�F/951 EH 1428