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1 I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) if TP-- 1 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 San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin with Local Heath DiSIn t, f rAST� ` �, ` 1-2 r M��ag" bf 'S�1 e—C 06 e pet NN 14 t7 - City µ Lot Size 800 AG' PM Job Address Sharpe Army D Owner's Name BMG Enterprises INTO ' Address 193 E Mf or gan St . _ Phone 209-5 21-8986 Perris , Calif . 92370 Contracto,No rth Valley Dr.L1lj SsInC. P.O . BOX 108 License No. 41.8834 Phone 16-82 --0 62 TYPE OF WELL/PUMP: NEW WELL 1-1t DESTRUCTION C1GG��, 5 �� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Z MOZit0�� we DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES DISPOSAL FLD. PROP. LINE �2� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 'a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom :] Manteca Dia. of Well Excavation 1 01t Dia. of Well Casing 411 ❑ Domestic/Private aGravel Pack ❑ Tracy Type of Casing SCh 40 PVC Specifications F1 , FI Public Other ❑ Delta Depth of Grout Seal � Type of Grout N R 2 t ['PMe .t� I I Irrigation )La-Approx. Depth I ) Eastern Surface Seal Installed by QP.meiat -' Repair Work Done ❑ Type of Pump 1 H.P. State Work Done Well Destruction ❑ Weil Diameter 1 Sealing Material Itop 501 Monitoring Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIRIADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) 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 1 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ` I 11 LEACHING LINE ❑ No. & Length of lines Total length/size " FILTER BED ❑ Distance toy nearest: Well Foundation Property Line SEEPAGE PITS I I Depth I Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ti 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 t rules and regulations of the San Joaquin Local Health District. Horne 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 applica must call f r all requir d inspections. Complete drawin on r)verse side. y Signed X Titl Date: 3—C FOR DEARTMENT USE ONLY Application Accepted by Date Pit or Grout Inspection by DatFinal Inspection b Date y" d Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 s FEE AMOUNT DUE t AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH Ir ILL III +.EH 13-24(REV.I/K 51 5r. EH 14-26 �l