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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone Q091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby 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 wellipump and the Rules and Regulations of the San Joaquin Local Health District. Job AddressCity Lot Size PM Owner's Name JV22WAMA Ch_�-AY'rsI24Address Phone a Contractor Ft_�'D�= u��iyf� Address? N. A r7c'c�s �: At/ License No.! i�Yl b Phone ,TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM-<RILPAIR ❑ OTHER ❑ pISTANJ9.E.•T_0_NE.A-8 EST:,SEPTIC;TANK } SEWER LINES DISPOSAL FLD. _ PROP. LINE w FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WEE L PROBLEM AREA"i.CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom❑ Manteca), Dia. of Well Excavation :`ti Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Fl Tracy 141 Type of Casing Specifications �l l`l Public 1-1 Other Cl Delta 1. Depth of Grout Seal f Type of Grout I I Ngation _.Approx. Depth i I Eastern } Surface Seal Installed by Repair Work'Done ❑ Type of PLmp 4' + HP `f �+ State Work Done WeII.Destruction D' Well Diameter " S alingMaterial Itop 50'1 r � Depth T +_ _ Fill ei Material IBeIOW 50'1 TYPE OF SFPTIC WORK: NEW INSTALLATION')1 REPAIR/AD.DITION DESTRUCTION YfNo septic system permitted if public sewer is `': f - ~-- =,'� '"-_.,_ - available-Within.200 feet.) Installation will serve: Residence_ Commerciale Other Number of living units: _ NGmber of-bedrooms �✓ _ Character of soil to a depthh f 3 feet: �'r _ M rt Water table'depth SEPTIC TANK CiY' Type/Mfg 'G - 1°F'r e `s 1 Capacity..i Zer d -No.-Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well `.Foundation t /tl Property-Line 42.` LEACHING LINE, No. & Length of lines. -� // ' 1 Total length/size 2- FILTER FILTER BED ❑ Distance to nearest: Well-. Foundation r 7-d Property Line r, SEEPAGE PITS iPr Depth ya Size Number j SUMPS L1 Distance to nearest: Wel] A�IA Foundation=_._��_� Property tine. •DISPOSAL PONDS ❑ I hereby certify that I have prepared this appiication_and_that_the work will be.done-intaccordance 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections.-Complete drawing on reverse side. Signed Xfi� _ i &ZiTrs __ _ Title_ t��.s✓t-t- 3 Date: s FOR DEPARTMENT USE ONLY . ea ° �q ►i�} Application Accepted by Date^ � �►/" Area J Pit or Grout Inspection by Date s` ! Final Inspection by Date Additional Comments: ��S l s olt7/ro ❑ Stk 466-6781 t7l Lod 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 FEE i INFO MOUNT DUE OUNT REMITTED C K H RECEIVED BY PAT PERMIT NO. + EH 13-241REV.s/As1 1,5121d / -. EH 14-28 ITZ, I yj-