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APPLICATION FOR PERMIT 4. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 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. Job Address City Lot Size ;!S;X�� PM Owner's Name 14 Address WAS is 0SEAll5w C 4E Phdne Contractor * == AddresLricense-N —Pho TYPE OF.WELL/PUMP""`"" "'--""`NEW WELL E]--�-- _—WEL•k R_CPLACEMEN-T M- .=--DESTRUCTJON.C] �=� PUMP INSTALLATION ❑ eSYSTEM REPAIR ❑ ~BOTHER ❑ DISTANCE TO NEAREST:'SEPTIC.TANK� SEWER-_LINE_S ____- - _ _- DjSPpSAL FLD. PROP. LINE FOUNDATIONI AGRICULTURE WELL OTHER,WELL f` PITS/SUMPS INTENDED USE 1�TYPE OF W1ILL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ► I ❑ Industrial q` ;❑ Open Bottom` G1'Manteca r- Dia. of Well Excavation ! ` Dia. of,Well Casing ED Dom estic/Private 4C3;Gravel Pack 4 ❑ Tracy � � Type of Casing �'-- Specifications #£t Ll Public f Other '. CI Delta ;� ; Depth of Grout Seal t 1 I Type of Grout I I Irrigation Approx. Depth I Easfem' *` Surface Seal Installed by l i Repair Work Done L9 ,Type of Pump t r,_ H.P. StatWork Done— Well Destruction ED -'Well Diameters Sealing Material [top 50') Depth �y � Filler Material (Below 501 0 - g TYPE OF SEPTIC WORK: NEW INSTALLATION (..)-,-REPAIR/ADDITION) _DESTRUCTION I-1_iNo-septic system permitted if public sewer is i I availabWwithin 200 feet.) Installation will serve: Residence-A Commercial_ Other - t _ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: " ' Water table depth SEPTIC TANK il�M!Zr 13 Type/Mfg Capacity No. Compartments I ` PKG. TREATMENT PLT. ❑ y Method of Disposal d�Lunclation Distance to nearest: Well Property Line 1ff 1 ftw. LEACHING LINE No. & Length of lines AVNV= 3 i Total length/size . FILTER!BED O Distance to_nearest: Well ,t�undation Property Lin SEEPAGE PITS " i I�Depth S Size Number t SUMPS 1 Ll Distance to nearest: Well Foundation Property Line y DISPOSAL PONDS . ❑ • ,w,_. -� r "_ .. _ ... -- , ..,.- --- - --: 1 I hereby certify that I have prepared this application and that the work will be done in accordan6e with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local'Heahh 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." y The applicant must call for all required ' spe ions. Comple drawing on reverse side. �.,,. Signediipe! 1 Title: �sF DEPARTMENT USE ONLY a iii L�-S 0 P.Irout ieion Accepted by Data �` `t V - Area I Inspection by `✓v f Date ^� Final Insp--'' n by Dom•^t �� Additional Comments: .rx. � y-�--• '-+=` n .�. ,:�. -:. El Stk k 466-6781 ❑'L,-:Ii ._ 1 L',tw,theca 823-7104 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 . F_..-..... FEE CK, l AMOUNT DUE AMOUNT REMITTED -N i CASH RECEIVED BY DATE PERMIT'NO. + EH 13-241REY.I/ns) �L, t il Li oo 119 �A 1"�f f Q EH 1428 V v ��b l "� I