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i APPLICATION'FOR PERMIT SAN JOAQUIN LOCAL. HEALTH DISTRICT r 1601 E. HAZE T ON AVE., STOCKTON, CA f 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 her described.-This application is made in compliance with San Joaquin C�unty 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 7?W Cy_ 13L Ve City Yf�G Lot Size W44"'el( PM j mac` / ryf!U e/0 Owner's N1'% Addr^�e�ss Phone Contractor �7/1/r LT f�t�ddress , neW R4P V/fr �10 C T �f/� " License No, p Phone TYPE OF WELL/PUMP: / - NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t 7�f PUMP INSTALLATION ❑ "-SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST':—SEPTIC TANK ''' 4 SEWER,"L`INES DISPOSAL FLD. PROP. LINE _ FOUNDATION,, a'AGRICULTURE°WELL OTHER WELL PITS/SUMPS INTENDED USSTYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATIONS Ll Industrial El Open Bottom ❑ 'Manteca,�Y Did. of.WeII..Excavation r Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑tTracy z Type of Casingr Specifications f`1'PubGc f 1 Other l-1 Delta i Depth of Grout Seal1. I I Irri ation Type of Grout _ g --App 10 Eastern f Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done, Well Destruction ❑ Well Diameter ° Sealing Material (top 50') Depth. Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW'INSTALLAT r I ION I:} REPAIR/ADDITION I 1 DESTRUCTION{ I (No septic system permitted if public sewer is -� T I It 'available within 200 feet.) Installation will serve: Residence A Commercial_ Other 'available Tt�" Number of living units: _ / Number of;bedrooms JV r Character of soil to a depth of 3 feet: I G C�1 L a.Rr Water table depth SEPTIC TANK Type/Mfg .�y� �fJ� Capacity_LA -_ ^ No. Compartments -Z PKG. TREATMENT PLT. ❑ ) i Method of Disposal ' z. Distance to nearest: Well Foundation_ I� ll X00 --.e-- Property Line" /M0 t LEACHING-LINE Y I VI j No. & Leng, of lines 4Q Total length/size IrP� FILTER BED""' r " ❑i ;. Distance to-nearest: Well Foundation t e7 Property Line �AO SEEPAGE PITS i I - Depth EI �f J7` Size f�" ` X f0' Number SUMPS t IX Distance_-te nearest: Well /00 _ Foundation 540` Property Line -:70DISPOSAL PONDS ❑ 1 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 r 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, I shall employ persons subject to workman's compensa- tion laws of California." I I The applicant must inspections. Co required ins call for all re ,. q mplete drawing on reverse side. - r Signed X II Title Date- FF EPARTMENT USE ONLY 'Application Accepted by LAS �' s .pate Area t Pit or Grout Inspection by Date—.Final Inspection by f Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621'-".,, ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return 811 copies to: Environmental,Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED -4 INFO CASH RECEIVED BY DATE PERMIT"NO. + EH 13-24 tREV.riHsY �©� EH 14-26 - P0 ' _r-• � fig— 1