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w 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 { IComplete 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. F+ Job Address 11180 VA{te1 O CT City FA- CAMP- Lot Size PM Owner's Name (� 1�V 19 f Af'S 0 Address Phone` � 4 N-7 4 I - t Contractor �!r,! 1CA4(or(C Address r I& V1TQAJ AV JZ License No.2(4311 Phone 236 say TYPE OF WELL/,PUMP: NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION ❑ PUMP INSTAL"LATION_❑ SYSTEM REPAIR LI OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL RLD. PROP. LINE —FOUNDATION. --AGRIC LTURE.WELL !�O_TH>:R WELL_�`'"y. - „PITS./SUMP_S__ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' , ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation -Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications x� ('1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout--- I rout _i I Irrigation Approx. Depth E I Eastern Surface Seal I taller' by `Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 141' REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted if public sewer is # available within 200 feet.I Installation will serve: Residence_ Commercial Other J w Number of living units: Number of bgorooms F w �I `ii Y Character of soil to a depth of 3 feet: A�,-Ov L-A 1-1 _ F Water table depth SEPTIC TANK Type/Mfg. Pf 4'4 r Capacity r 0()—.! No. Compartments PKG. TREATMENT PLT. ❑ R r Method of Disposal w Distance to nearest: -Well too Foundation 10 a Property Line a iLEACHING LINE •[R""No. & Length of lines d 1 fav Total length/size O(1 r r FILTER BED ❑ ,Distance to nearest: Well Foundation Property Line i SEEPAGE PITS I I Depth' Size _ Number SUMPS Distance to nearest: Well . Foundation Property Line 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, 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 performa ce•ofth work for which this permit is issued, I shall not employ any peI in such manner a_s to become subject.to workman's compensation laws of California." Contractor's hiring of 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." U^ The applicant must call for all required in ctions. Complete drawing on reverse side. Signed X I � Title: O AuA,ef%-, `r Date: FOR DEPARTMENT USE ONLY Appfcation Accepted by 2� �, Date- Pit or Grout Inspection.by� Date, Final Inspection.by _.. _ _.. __.__---Date Additional Comments:} U ❑ Silk 466-6781 ; ❑,,Lodi(-369-3621` ❑ Manteca' 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies,to: Environmental Health Permit/Services 1601 E.-Hazelton Ave., P.O. Box 2009,'Stk., CA 95201 FEE AMOUNT DUE/ AMOUNT,REMITTED C RECEIVED BY DATE PERMIT"NO." INFO H EH -24 /�} /�} +.EH t4-28IREV.tiH51 D tL f / • "L