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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 Local Health District. nn Job Address 00e eoctc4. City --Ile L) Lot Size PM Owner's Name 1652 d is k Y Alla y TrAddress 13' f S- S . t44L+Ck I'-,S ,.LCi aL i Phone fv rr yC 0 Q SS ,L Sr r, - Pk gg o -s4.,l 4vn 131,4. 0,41 - I-r.?X 63 7 4t 5-/ -5 9 7 T Contractors 1--MIN g ga�fr TA,vICAddress IP-013 c tr 76 7 koct i License No. 3:X 8 Phone 3 TYPE OF WELL/PUMP: ~NEW'WELL'' WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMV INSTI LLATION 19 • '',SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 93SEWER LINES 4, DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL A/O AC PITS/SUMPS 'f T INTENDE US f. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r_1 Industrial 1A Openottom ❑Manteca Dia. of Wel Excavation i_, la. of Well Casing [:Domestic/Private � O Gravel Prt ❑ Tracy Type of Casing Ste e_1 t/bGA-.. cations A/ 6' c+*e. ❑ Public ❑ Other ¢� ❑ Delta Depth of Grout Seal Sb Type of Grout C/ S" ❑ Irrigation rdT-Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Oump Sy6. H.P. ��L State Work Done 3`fr�3 Well Destruction ❑ Well Diameter 12. Sealing Material (top 501 (2W_ft27 Depth r�rA ' Filler Material (Below 501 CYi+„«aq TYPE OF SEPTIC WORK: NEW INSTALLATION X REPAIR/ADDITION ❑ DESTRUCTION ❑ (No soptic system permitted if public sewer is rh I�S �+ C Qh 1/1/G . Cdltivlc� /L_C t* ��, ,� avatabA within 200 feet.). 1 Installation will serve: residence_,L Commercial_ Other Number of living units: _Y__ Number of bedrooms 3 j Character of soil to a depth of 3 feet: HanLrd L," n � Water table depth t f0 SEPTIC TANK W` Type/Mfg Lf)1V1,-'S Sell ft C Capacity—i 1_00610 No. Compartments- PKG. ompartmentsPKG. TREATMENT PLT. ❑ !Method of Disposal Distance to nearest: Well Foundation /d r Proderty Line '10` LEACHING LINE 5?- No. &Length of lines 3 - ZIP ' L1„ cis Total length/size '�6r FILTER BED rV14 ❑ Distance to nearest: Well Foundation Pro�erty Line SEEPAGE PITS 21" Depth Size 3-3 Number SUMPS ❑ Distance to nearest: Well FoundatidW Property Line f DISPOSAL PONDS ❑ I hereby certify thet I have prepared this application and_tbat the work vdilhbe done in actor nce with San,Joaquin cou finances tat 4;s, rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the follpwing: "I certitl.that in the perform nce of the work for which this permit is issued, I shelf not employ any;person in sach manner as to become subject to workman's compensation laws of alifornia. Contractor's hiring or sub-contiacting signature certifies the fpllowi0g:"I certify that in the performance of the work for which this permit is issu ,I shall bmloy persons subject to Workman'scompensa- tion laws of". f`California." The applica t call for all required irop�eottgl ts.,f:o 4et-�rawing on reverse side. ,u Signed '° Title: -e Date: 7 5` -FOR.DEPARTMENT 1,16916ftLY v i >1 Application Accept@ ,' r D '_ Area 0 +ar Grult eInqec' y Date 1A4aFcti y •bate, W .+ Additional gomm$nts: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M 4 Applicbnt•-aReturrfal dopiesvto: Environmental Health Permit/Services 1601 E. Hazen Ave., P.O. Box 3M; Stk, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ?Stsl, w� + EH 3-24(REV.1/85) /S,O vc) 1/„? EH 1426 tit w ! 0 V-ti P