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APPLICATION FOR PERMITPA Y Nrt+:F- SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {2091 466-6781 �{ 2 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 herein described. This application is made in compliance with San Joa in County Ordinance No. 549 for sewage or No. 1662 for well/purnp and the Rules and Regulations of the San Joaquin Local Health District. Job Address City �t Lot Size PM 1� .2 /I/7/1e2 6e- Lzzr� Owner's Name +� vr rG AddressPhonee estr�rA�l7' Gc��SS /�sscr�,gr�S a�3S "I 6V4klc7.1cl� Q. Contraclor��ttS�E��c. l.V� Address 1,3"-yi?st;�6L0Y40Qst/\70.Sense No. 5Z4/3`-tPhone 9 3 TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT ❑ DESTRUCTION ❑ �J r PUMP INSTALLATION [] SYSTEM REPAIRISPOSAL FLD, OP, LINE OTHERf �� DISTANCE TO NEAREST: SEPTIC TANK __. SEWER LINES 35 FOUNDATION OZo� AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i I Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation l— Dia, of Well Casing [l Oomestic/Private n Grave! Pa ❑ Tracy Type of Casing.+ YGS h�rz 40 Specifications 1'1 Public OtherF-1 Delta Depth of Grout Seal Type of Grout _ I i trriulat+on _ Apftrox. Depth, I I Eastern Su1rface Seat Installed by S ` ��r C -A Repair Work Oftne [_I Type o1 Pump IA H.P. " / Stale Work Done Well Destruction Well Diameter Sealing Material (top 50') AD Depth Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ! I REPAIR/ADOtTION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence_ Commercial_ Other Number of living units: __ Number of bedrooms Character of soil to a depth of 3 feet: i...,._ —Water table depth SEPTIC TANK L-) Type/Mfg Capacity No. Compartments _ 4KG. TREATMENT PLT. Ll Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE FI No. & Length of lines _ Tota! length/size _ FILTER BED [1 Distance to nearest: Well __ Foundation Property Line SEEPAGE PITS I I Depth ,_ ____ _Size Number SUMPS l 1 Distance to nearest: Well Foundation _ Property Line DISPOSAL PONDS I 1 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. j 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." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X / Title: l7iDf J ' f I FOR DEPARTMENT USE ONLY Application Accepted by � } Date - '�c/ Area Pit or Grout Inspeclian by G�' Date r�5 `' Final Inspection by ��``9. Dale Additional Comments: L7 Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 1335-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 tFEO EE AMOUNT DUE AMOUNT REMITTED CK n RECEIVED BY DATE PE(}R"=EMIT NO. EH 13-24 IREV.r i n 5J 3��. ��.�. PICLAIS EH 14-28 l 7`