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APPLICATION FOR PERMIT M v SAN JOAQUIN LOCAL HEALTH DISTRICT 1601-,E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 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/of 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 �V. /Z_0 City Lot Size ' /44dgf' -S PM Owner's Name Address ,T,*Py r Phone Contractor t140V,12 a . Lrl.,o�� Address re aex CV-2) r_ License No. i y76 Phone TYPE OF WELL/PUMP: NEW WELL ❑ t WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE-WELL- — -OTHER WELL PITS/SUMPS " INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSe i 11Industrial ❑ Open Bottom•) ❑ Manteca Dia. of Well Excavation Dia. of Well.Casing ❑ Domestic/Private ❑ Gravel' ❑ Tra`cy \Type of Casing ' ` 1 Specifications F1 Public �❑ Othersf_ 1-1 Delta Depth of Grout Seal '-?� Type of Grout - I I Irrigation =_Approx.! Depth I I Eastern, Surface Seal.lnstalled_ by _ Repair Work Done ❑ Type of Pump �` H.P.. _ �r''"X State-Work-Gone_-- x Well Destruction ❑ 3Well Diameter '__ _ Sealing Material{top 501 Depth) -.Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW;INSTALLATIWI.1 REPAIR/ADDITIONX DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_Z Commercial_ !Other"' Number of living units: / Number of bedrooms_ r Character of soil,toI a-depth of 3 feet: Water.table depth SEPTIC TANK 0,,- '-11 Type/Mfg r_.i.5.1-706 Capacity /d d 0 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines �_ "��® Total length/size /OX 45 1 `2r FILTER BED C/Distance to nearest: Well..., /SQ-f Foundation Ae' Property Line 7- SEEPAGE PITS (14"Depth p Size._-_.-_42 Number SUMPS Cl Distance to nearest: Well Foundation��._.... Property Line 7S DISPOSAL PONDS Ll { I 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 rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies.the following:.1-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." ,- t I The applicant must call for all required insl�� ~ j ' ' 1 q pecUons. Complete on reverse side. k% Signed X 'Title: Date: °5'2-'8. FO NJ USE ONLY 7 Application Accepted by f:� A4,. rr L, Date SArea 12 Pit or Grout Inspection by Date Final Inspection by Date -• I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 wr FEE MOUNT DUEEAMOUNT REMITTED CK RECEIVED-BY DATE PERMIT*NO. INFO CA H 7 a EH i'3-24(REV,t/e 51 0�-" J!� !.• EM 14-26, -7D Q� !+ �� kf—/I/7pz r if