SITE INFORMATION AND CORRESPONDENCE FILE 3

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i II APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE„ STOCKTON , CA ii Telephone (209) -466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _ . Ik •: ' . (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 Rules and Regulations of the San Joaquin Local Health District a �( 7 �IA u 1aTR v C /u B 13 I vb- cty STKH ' Lot sae %H �cag PM Job Address , � . - . - owner's Name Jo h N EOS61rle 12 Address' - VSAM -E -'/a- S _ A13 0 V - Phone 5%(0 Contractor J40ACK ih AddressoqSOO F14 EY»ON7 .STLicense No. . 3 .9 13 Phone $ / TYPE OF WELL/PUMP: I,NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR fl OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK=L--- — SEWER LINES DISPOSAL- FLD.— PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 11 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 LSpecifications ❑ Public ❑ Other II ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation - --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ® Type of Pump Z LJ S H. P. PIA. State Work Done n Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth 1 Filler Material (Below 509 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION L7 DESTRUCTION El (No septic system permitted if public sewer is N available within 200 feet. ) �^ Installation will serve: Residenceal_ Commercial _, Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: a Water table depth SEPTIC TANK ❑ Type/Mfg t Capacity " ` 4. . 4. � No. Compartments PKG, TREATMENT PLT. ❑ i Method• of Disposal Distance to nearest: Well Foundation Property Line s LEACHING LINE ❑ No. & Length of lines ' � ' - Total length/size FILTER BED ❑- Distance to nearest: Well Foundation Property Line II SEEPAGE PITS - ❑ Depth 'II' Size Number - SUMPS ,. ❑ Distance to, nearest: -. Well t` l .Foundation. T c Property Line ` DISPOSAL PONDS ❑ 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: "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." Contractors 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 workmen's compensa- tion laws of California. " �t . . The applicant must call for all required inspections. Complete drawing on reverse side. , II ��t' �vra<li.�ll� '4 - - Da ; ,u va Signed N gl" Ar/ 4Aa- Title: t, ENT USE ONLY / "T iT, ! F R EPARTM O / "' rt• _ `... Application Accepted"6 !/s wC-f Ci ? ��" Date 7rAlt a � A Pit or Grout Inspec ' II Date Final Inspection by Date f I • - Additidnal Comments: r Cl Stk 4WO781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835MM _ - C � M Applicant - Return all copies to: Envlrpnmerltal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20091 Stk. , CA 952(i"N t t'J h FEEFO AMOUNT DUE AMOUNT REMITTED , ' CASH CK 4 RECEIVED BY DATE PERMIT'No, + ER 13-241REV. 1 / 85) EH T&M IN