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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STQCKTON, CA . Telephone (209) 466-6781 I� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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 wellipump and the Rules and Regulations of the San Joaquin i Local Health District. ii I � 7 � zI ?Job Address ��7 •+ ' , City 4CA Lot Size `� AC" PM Owner's Name DbaalD Address 230em. Phone Contractor C o *G.: C i diva Address��JF_y ,91A 411 License No.%f0S� 0 / Phone AbA�T3� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications f Publ c F1 Other Ll Delta Depth of Grout Seal Type of Grout _ I i Irrigation !Approx. Depth 1 I Eastern Surface Seal Installed by s _ T Ay Repair Work Done 0 Type of Pump H.P. State Work Done� I "V Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material lBelow 501 f I TYPErOF SEPTIC WORK: NEW INSTALLATION 1p-REPAIR/ADDITION E I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Res dente Commercial Other .1 Apu- Numller of living units: Number of b drooms 3._._-. f Character of soil to a depth of 3 feet: �— Water table depth �.+ W SEPTIC,TANK 111 Type/Mfg C-6.10.T ~`-G 4 a Capacity Qd No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: 'Well 100f Foundation Property Line j LEACHING LINE No. & Length of lines t.7�'___ a �r ��To�ttal length/size f j "IFILTERiBED I- Distance to nea e�t )Well t Foundation SC._.._.._.__ Property Line SEEPAGE PITS Ice Depth s-.�15 Size 3& Number .3 + SUMPS ❑ Distance to nearest:,I Well Foundation Property Line DISPOSAL PONDS ❑ J -ftjIt I hereby certify that I have prepared this application and that the work will be done iri,accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. tJ i Home owner or licensed agent's signature csrufies theifollowing: "I certify that in i:h'e performance of the work for which this permit is issued, I shall not employiany person in such manner as to become subjdct to workman's compensation'laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the perfofn4wr:iii of the work for which this permit-is issa ed, I shall employ persons subject to workman's compensa- tion laws of California." {i The applicant must call for II re iced in7ctions. Complete drawing on,�reverse side. Signed X Title: 4l 464) Date: L `tt.O FOR DEPARTMENT USE ONLY Application Accepted by Date Area 42-• ,vim Pit i rout Inspection by ate / incl Inspection by Dat Additional Comments: ❑ Stk L466y6781------B---odt X69-2624------©-Manteca--7-l-04_._..—Q Tracy.--835-.6385 _ Applicantf Return-all copies-to: EnvironmenttAl 1,4a—Ith Permit/Services-1,601 E. 1 azelton-Ave., P.O. Boxi2009,,Stk., CA 95201 INFO KI FEEAMOUNT DUE AMdUNT REMITTED CASH RECEIVED BY PATE 4 PERMIT(NO. r.EH 13-24 IREV.I/n 51 /��,� EH 14-26 t1 LJ �./ f