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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR'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 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. + oe f{Far9I Lot-Size. -P M Job Address - ' / rye . fay'oq$s1-,&..y4/ city ..d r 1=. -.. .�;0�w g//6 LfiTfiro 64 •. �•Phone,-.. Owner's Name HiChApel- W.9yr -"Address 4 _ tl° _ ,� mop Addresses�Lr✓� License No.YP> �/ Phone,- �'� Contractor /�� TYPE OF WELL/PUMP: -"' NEW WELL'❑•- WELL REPLACEMENT 0 ^" DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ iI DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom 171-Manteca Dia. of Well Excavation Dia, of Well Casing ❑ Industrial I 1 S Specifications I ❑ Domestic/Private ❑ Garavel Pack : ❑ Tracy Type of Casing Type of Grout I'1 Public F] Other s l-1 Delta Depth of Grout Seal Approx. Depth l I-Eastern 'Surface Seal Installed by 1 I Irrigation ; — State Work Done Repair Work Done Ll Type of Pump H.P. Sealing Material 50'i } Well Destruction ❑ Well Diameter 9 p , Depth Filler Material iBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Jrfi�REPAIR/ADDITION l 1 DESTRUCTION I 1 availablINo et1within 200 feeft�ed if public sewer is installation will serve: Residence-It C'ommercial Other Number of living units: Number of f bedrooms Water table depth Character of soil to' 'depth�of 3 feet: a SEPTIG TANK Z TypeIMfg ! C Capaelty Joao No. Compartments PKG TREATMENT PLT. El to of Disposal Distance to nearest: Well J OO Foundation s Property Line J►3 ' $ - 9O �P - LEACHING LINE � Total lengthlsize t No. & Length of lines FILTER BED ❑ Distance to nearest: Well /VFoundation 3S" Property Line 33" {7i/Y• SEEPAGE PITS". VNumber Depth �S� Size SUMPS ' _.` ;�L� Distance to nearest: Well aG- Foundation VOfOf Property Line k s l 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. r 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, 1 shall not to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature employ any person in such manner n certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of California." The applicant must p1l for all required inspections. Complete drawing on reverse si Ir" Signed X Title: F Date: 91—/417, 0 9 •� FO RTMENT USE ONLY Application Accepted 6y ' - Date Area ate DFinal Inspection by Date �ar Grout Inspection by w k Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I r FEE AMOUNT-OUE;= AMOUNT REMITTED "CASH' RECEIVED BY- DA�TGE PERMIT'NO. E INFO 7V LTJ ��. i + EH t3-241REV.t/K51 EH 14.29 f