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%APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA /` O 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address 171&9 .S MI/L2,11/,( RJ) City L 4T t> t' Lot Size PM t?oX Owners Name C42 PC-/Q71r�'2 eO- Address 2 IC/1"'9'0412 , Ind Phone (toy) Contractor L(¢L-Li•: /'•1 C'CN 7J(. Address 'P•0 PUX 5-I24 i JLZaS License No..3.3.3.1 ( � Phone /-YO TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by s Repair Work Done ❑ Type of Pump H.P. State Work Done 1 Well Destruction ❑ Well Diameter Sealing Material (top 501 J_ Depth Filler Material (Below 501 Q TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is (1 available within 200 feet.) Installation will serve: Residence_ Commercial-�/ Other )' Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: Water table depth ^� SEPTIC TANK )I Type/Mfg ��t"��', P�L I�NC.lt2Capacity .3L� G' No. Compartments Z - ' \ PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Weil Foundation Property Line / _J D -4:4z� LEACHING LINE No. & Length of lines M X 100' L OV6 Total length/size— FILTER ength/size FILTER BED ❑ Distance to nearest: Well XS-0'' Foundation S-0 r Property Line 2-0 �1 SEEPAGE PITS C Depth Size Number /r\, SUMPS _. Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin county ordinances, state laws, and - 'Alonuin L_e-I Home owner or licensed agents signature cemfies the foibwing: "I certify that in the performance of the work for which this permit is issued, I shall not Q� employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature c 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 must call for ail ra uirad inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY D Application Accepted by _�- o" �t-r Date � Area Pit or Grout Inspection by 'VLA Date Final Inspection by Date � Additional Comments: 3 000 ak- K + 00 c for 00 e-m (o P-e ?700 j, /+1ov'- t r\ ❑ Slit 466-6781 ❑Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 OQWM. V\ 1 Applicant- Return all copies to: Environmental)*Ith Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 1 / Vk rG S'}�-/n or ofh (-e_5+ -C,0mS OY) I NFEE FO AMOUNT DUE AMOUNT RMITTED CASH Cr 4 RECE ED BY DATE PERMIT NO. yL____( 1, 6— PiI'iDUtnyMvP` SEH 1324 IREV.ri a sl p7 ��--� `�' Y`O p S -�G9$ 30Z)e1r1 EH 1426 /'