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n APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA �t Telephone (209) 466-6781 �l,��O, ;(1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED !d (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct ar / istall-Jhe —rk iFi described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 11362 for td ,fti and Regulations of the San Joaquin Local Health District. 4i Job Address LI�I'�Jr�� /T7r L City Lot Size PM Owner's Name �Yv' Address ��`L� Phone �f'�3 Contractaar`-iVifLVVA1yP Al Af� Address_--K41«_ / __ License .No� 2�7Phone?'?T7DZ-7 TYPE OF WELL/PUMP: NEW WELE77 . WELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATION J;; SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS IN DEQ USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT O Industrial ❑ Open Bottom © Manteca Dia. of Well Excavatio10 J 7 Dia. of Well Casing $ ❑ Domestic/Private "' I Pack C1 Tracy Type of CasingT � Specifications M Ul Public th,5 Alt #'K- Cl Delta Depth of Grout Seal ^-�j1� Type of Grout _. I I Irrigation " .Approx. Depth { I Eastern Surf ce Seal Installed by X L?/"4C— hzAzg�y6� r✓ _ , y Repair Work Done ❑ Type of Pump v6rn H.P. State Work Done Well Destruction ❑ Well Diameter Sealing aterial (top 501 M Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) �3 Installation will serve: Residence— Commercial_ Other !Number of living units: Number of bedrooms .w Character of soil to a depth,of 3 feet: Water table depth C SEPTIC TANK ❑ IT ype/Mfg Capacity No. Compartments 4 PKG. TREATMENT PLT. 171� Method of Disposal Distance to nearest: Well Foundation Property Line Ip LEACHING LINE ❑ ,No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line T SEEPAGE PITS I l Depth Size Number SUMPS LlDistance to nearest: Wel! Foundation Property Line DISPOSAL PONDS ❑ 9 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances A"Je laws, and T 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 whit r ��d, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Cont�ra,�toAs ��-contracting signature certifies the following: "I certify that in the performance of the work far which this permit is issued, I shall�gYplb rsp'A orkman's compensa- tion laws of California." 3 The applicant sicall f a (red inspections. Complete drawing on reverse side. Signed X ' Title: Date: Z iA y FOR DEPARTMENT USE O Y--.- �( Application Accepted by �l Date t3 Area ,I Pit or Grout Inspection by ' Date Final Inspection by �� Date Additional Comments: �Cr #-2-f `�/ Ile,n f / l ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca -7104 ❑ Tracy 835-638 ` Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I� FEE II INFO AMOUNT DUE AMOUNT REMITTED CK 0 CgH RECEIVED BY DATE PERMIT-NO. +.EH 13-24IRM 1/851 11 3S'o J 1,.D(AS7 75 EH 14-28r