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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. 14AZELTON 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 SJO 4C61W pa A?d a City 4C-1-1je0 Lot Size /v S PM Owner's Name d et kd"^ eth 1 1 Address i 3 1 S- S . l4"+C k 1',l S ,J-6 ct i Phone 3&Cr 41e ;Ov��4425K*`e_S& •R-Sek • /2Lvo -S+61,4vn valva. ball- J-r-?XG3 7w�1397 Contractors 74'wk Address PV 13 c Y 76 7 Lod License No. 3 S 1 1 0 Phone 3 / TYPE OF WELL/PUMP: NEW WELL.9 WELL REPLACEMENT ❑ DESTRUCTION ❑ PVM INST/ LLATION `.SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 93'` SEWER LINES t DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL I4p[_w-_ OTHER WELL—AW-4K PITS/SUMPS 1 yT' INTEND%US y. . TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Of>*O 6'evb� n Industrial I)L Open Potton ❑ Manteca Dia. of Well Excavation 1.1!! Ria. of Well Casing X Domestic/f rivate` _.E1 Gravel,P p Tracy Type of Casing S t e e_f 1161 G A-,�fications 'y k fio cn ❑ Public ❑ Other ❑ Delta Depth of Grout SealS b Type of Grout S-4-- • - 4--❑ Irrigation fWD—Approx. Depth ❑ Eastern Surfapa Seal Installed by Repair Work Done El Type of Pump ayb, H.P. ?_ State Work Done 3YS'�3 Well Destruction ❑ Well Diameter 1 ZSealing Material (top 501 Chi r<fcn lr Depth Clop ' Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION la REPAIR/ADDITION❑ DESTRUCTION ❑ (No s6ptic system permitted if public sewer is r M 1 V-S Fl�' 'TRre r(- 1l1lC . Coc'>itv1rtC'v, / c -3 a��l x j avaifa*within 200 feet.). 1 Installation will serve: esidence�X_ Commercial_ Other W , Number of livingunits: ( f^ �_ Number of bedrooms 3 i Character of soil to a depth of 3 feet: W42# d L.ce,.'1 Water table depth 110 SEPTIC TANK V Type/Mfg FRIVIA�'!S Se-12'b C. Capacity Ct7 ISOF-1 No. Compartment, 1�11 PKG. TREATMENT PLT. ❑ r 'Method of Disposal Distance to nearest: Well Foundation /O 1 Property Line LEACHING LINE 0" No. &-Length of lines 3 - y Lines Total length/size y�r FILTER BED 41/4 ❑ Distance to nearest: Well Foundation Pro4rty Line SEEPAGE PITS Z" Depth Size 3-3 Number SUMPS ❑ Distance to nearest: Well Foundatiov x Property Line / DISPOSAL PONDS ❑ 1+" "• %fir a � I hereby certify thit I have prepared this application and tbat.;he work vAbbe done in accor&Tnce with San,Joaquin cou inances Iat 'ws, rules and regulations ot the San Joaquin Local Health District. Home owner or licens d agent's signature certifies the folipwing: "I certifythat in the perform nce of the work for which this permit is issued, I shalt not employ any person in such manner as to become subject to workman's compensation laws of lifornia. contractor's hiring or sub-contracting signature certifies the followigg:- I certify that in the performance of the work for which this permit is issu ,I shall a ploy persons subject to workman's compensa- tion laws of,California." Thea Iica t call for all required i PP q n$po9 iarls.,�or4etra swing on reverse side. �a- Signed '_ ;Title: t '(t.1rf.�7/" Date: " Z. �^ `fOR.,DEPARTMENT USE 6f LY Application AcD }} Area x or qnq ln,gRec y Date M1�aF y i Date: 8 + .>A> Iditional Comm$nts: y�9 ❑ Stk 466-6781 Dodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applieltns--Retur►f all aoplesyto: Environmental Health Permit/Services 1601 E. Hazen Ave., P.O. Box ; Stk:,CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 1& /,J oV 241REV. /a5) , I^� EH 14.28 ! !S