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� i F ^� �^ APPLICATION FOR PERMIT n G–s7 SAN JOAQUIN LOCAL HEALTH DISTRICT q(, 1601 E. HAZE.T ON AVE., STOCKTON, CA AaAA-. , La1��P' Telephone (209)466-63431— PERMIT 66-6 431—PERMIT EXPIRES T YEAR FROM DATE ISSUED o� (Complete in Triplicate) Few 3� �fl w Cor,c, x dt' 160fi dti��a�� w . Applicatidn is hereby made to the San Joaquin Local Health Distri&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 Distri ?, Job Address 43t* YokutS Drive City �'O�l Lot Size 13 000 S.F. PM29-ti c PHA Properties Addres $ Phone 956 303 Owner's Nam4.4. G+��ss A �� /7g 3773' ��50� -eT Conlractor G Orl Address License No. � Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 2 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑. OTHER ❑' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 40' DISPOSAL FLD. PROP. LINE 0' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ::TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ElIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Type of CasingSpecifications ❑ Domestic/Private El Gravel Gravel Pack .❑ Tracy 1 I Public 1-1 Other F1Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth t t Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction [$ Well Diameter _8 4 Sealing Material [top 50'1 "''9. Depth 291 Filler Material (Below 50') JNo stem TYPE OF SEPTIC WORK: NEW INSTALLATION {1 REPAIR/ADDITION l 1` DESTRUCTION l I availabtiwithin 200 feetitled if public sewer is ey Installation will serve: Residence Commercial _ Other Number of living units: ' Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal to Distance to nearest: Well Foundation Property.Line ` LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line :I SEEPAGE PITS I 1 Depth Size Number SUMPS £Ll 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 taws, and rules and regulations of the San Joaquin Local Health District. rtify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I cc employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant n t c requir ins do s. Cflmplate drawing on reverse side. l 1-3 -.0- y, Signed X • Title: Date: 14121L6� FOR DEPARTMENT USE ONLY Application Accepted by - Data Area Pit or Grout Inspection by ? Date -If*126 Final Inspection by Date Additional Comments: ❑ Stk 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 J FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO �.EH 4 1-24 IREV.1/n 51 � ' �U s'� D •^' EH 1t2e