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APPLICATION FOR PERMIT " I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA SCANNED ANNED 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. I / Job Address 34 3So so, Bpi ypJ Rd, City 7YA GY Lot Size XO'ICY 05 PM Re Owner's Name VAI.LEV ,7 O C K Co, Address 313.5'0 $'O• g t' Y d 1?14 Phone .W 6 Contractor &y76,wyVAddress 13L- 0*7 ✓G License No.yykff9I Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ 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 M Public n Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth 1 I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION;R REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial 2L- Other Number of living units: Number of bedrooms A Character of soil to a depth of 3 feet: 009P SOJL tt IS7/>•VC(. Water table depth Co SEPTIC TANK 419 Type/Mfg '0070 C497 Capacity—LA—OO No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 3QY LEACHING LINE QI No. & Length of lines 6 0 Total length/size O FILTER BED ❑ Distance to nearest: WellO/ 00' Foundation AS" Property Line 904' SEEPAGE PITS I I Depth Size Jr1A U r X 10 I Number f SUMPS lel Distance to nearest: Well /000' Foundation 90' Property Line Yoe DISPOSAL PONDS ❑ 1 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 performance of the work for which this permit is issued, I shall not 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mus call for all required inspections. Complete drawing on reverse side. Signed X d Title: Data: S" $O-' 90 DEPARTMENT USE ONLY Application Accepted by LCr Date `S / /fid —.Area a!6 Pit or Grout Inspection by Date Final Inspection byDate 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 FEE�_,.. INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. • 14]e(REV.I 18 EEH 13-24 H 5) O ♦ o — b/I� y o