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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT � 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �. (Complete in Triplicate) 3 District for a permit to construct and/or install the work herein described. This application is Application is hereby made to the San Joaquin Local Health made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. s Job Address / City SMS/ Lot Size-Zk � X 7- PM t ' Owner's Name P,4 WL REIP - Address 5 - Phone ' { Contractor FLO W O Address Al, AGL .e 114 License No.3�Xr�7'7G `Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARESTi SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION"SPECIFICATIONS r dustrial 'D Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing ❑ In `Y r,. "_ Specifications ❑ Domestic!Private 0❑ Gravel Pack ❑ Tracy Type of Casing M Public j❑ Other ❑ Delta Depth of Grout Seal Typewof Grout _ Approx. Depth I I Eastern Surface Seal Installed by - I I Irrigation + 4 Repair Work Done C3 (Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter ; Sealing Material (top 501 Depth Filler Material (Below 50:) t TYPE OF SEPTIC WORK:= NEW INSTALLATION X RFPAIRIADDITION [ I OLSTRUCTION'i I.tNo septicsystem.permilted_if-'public_. .... is�r lavailable within 200 feet.l f Installation will serve: Residence'�+ Commercial Other f j f ^� 4y' Number of living units: _L Number of bedrooms /} -4. -m--,-11+ ! Character of soil to a depth of 3 feet: 4 In ,f Water table depth Or SEPTIC TANK Type/Mfg -AL— '�"""'Capacty 19De�'�Nb`Compartments 7 .Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well - 6W Foundation �� Property Line LEACHING LINE No. & Length of lines z - g� -'� yam" Total'Eengtf�/size X70 �X 2.° F FILTER BED ❑ Distance to nearest: Well 72-7-a Foundation s Property Line SEEPAGE PITS iV Depth Size f3 40, _ Number i "w f SUMPS Ll Distance to nearest: Well 1�b0 I Foundation 90 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 Diltrict. 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 i employ any person in such manner as to become subject to workman's compensation taws of California." Contractor's hiring or sub-contracting signature certifies the following! "I certify that in the rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." i The applicant must call for all required.-inspections. Complete drawing on reversesid. f Signed X Title: —'Date: //_ .74 _.?19 Y "DEPARTMENT USE ONLY 7 2-11 Application Accepted by Date Area ' Pit or Grout Inspection by Date 1� 7 Final Inspection by pate �i 1 ' Additional Comments: S '466-6781 �,.0`Lodi 369-3621 0 Manteca 823-7104 17 Tracy 835-6385 Applicant -.R�rn'i3ll copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 SK/ IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH CK 4 RECEIVED By DATE PERMIT•NO. d 7 +.EH 13-24{pEV.i i N 5) + i - EH 142a