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APPLICATION FO, PERMiT SAN 11111IN LOCAL 11711TH DISTRICT /_ 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT N0. O'�7 —3 b 6� f Telephone (209) 466-6781 7 ; DATE ISSUED 7 3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED it (Complete in Triplicate) Ip � 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.Joaouin Local Health District. Job Address 2 � �M Subdivision Name 4C� erg �r+�°°s � '�� "00a r Owner's Name a Address 0. 0/ Ja[ Phone IRA WOO Contractor's Name License No. Phone 3 91— 90 5O. TYPE OF WELL/PUMP WORK: I` NEL! WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ,.r PUMP INSTALLATION .❑ SYSTEM REPAIR ❑ OTHER [7j W DISTANCE TO NEAREST: SEPTIC:,TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS „F 0 INTENDED USE �N TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial E] Open Bottom ❑ Manteca Dia. of Well Excavation �} ! ❑ Domestic/Private 0 Gravel Pack ❑Tr cy Dia. of Well Casing ❑ Public ❑ OtherWEt Type of Casing 77, Irrigation AApprox. �y Depth Specifications ❑ Cathodic Protection - Depth of Grout Seal ❑Geophysical l5l Type of Grout tt�� ❑Other Surface Seal Installed by i Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth:l!lIFiller Material (Below 50') � �E. i.r ■rin�u TYPE OF SEPTIC WORK: NEW I,NSTALCATION � REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is i , �, available within 200 feet.) Installation will serve: Residence Commercial Other Number of liv-irig units: `Number of bedrooms Lot size Character of soil to a depth of 3 feet. C,�1 Water table depth I:J i SEPTIC TANK � A Type/Mfg Capac4{ ty �jg No. Compartments PKG. TREATMENT PLT, [� Type/Mfg ti p y Ca ac@t Method of Disposal SEWAGE SYSTEM Distance to neErest: Well Foundation( / Property Line DESTRUCTION dk 1 11 - LEACHING LINE X li. & Length bf. lines a Total length/size FILTER BED [] Distance to nearest: Well Foundation Property Line :I SEEPAGE PITS Depth s Size r l_ Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS F5 !i�' ZR hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county I her y y p p pP � 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 workmans compensation laws of California." "Contractor's hiring or subcontracting 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 compensation laws of California." The applican must call for 311 required 'nspections Complete draw ng on r ver a side./ ,Signed X G�fy_ /!L T1�� `f Title: •_e27 GpDaatt'e R DEPA ENT USE ONLY -Area,-Il �tk 466-6781 Application Rccepted _ ,___- - , Additional .Comments odi 369-3621 .il _ Pit or Grout Inspection by Date /,7 —/ Manteca 823-7104 Final Inspection by Date l Tracy 835-6385 Applicant - Return all cop es to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO '� 4 S --fn X-1 13 S-1 blo ` EH 13-24 RFV. 10182 r to/gz 500 Q.� �' 14-26 (J{` �UO r�