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4* APPLICATION FOR PERMIT 10 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE`TON AVE., STOCKTON, CA Telephone (209) 466-6781 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 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. Job Address SWM &RU E>Sec:1–_ City 1_#,A+ARC212 - Lot Size NIA PM Owner's Name Address 1_b=490 CA Phone Contractor hjogTH Vk I 1ILLi WC-t1kddress 7000 P AW.License No. X41E��.Phone 2324 701 k2l TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 0 DESTRUCTION El, PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER'V MCN rMlZ f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FLD._ PROP. LINE FOUNDATION AGRICULTURE WELL — OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial El Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing 44 E) Domestic/Private Gravel Pack El Tracy Type of Casino PVC Specifications M Public n Other 171 Delta Depth of Grout Seal Type of Grout—,--. I I Irrigation tlc6 di- 6 .Approx. Depth 11 Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction El Well Diameter bi Sealing Material (top 501 =/I Cewrif-I Fit Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) 4!t ism Installation will serve: Residence— Commercial— Other Number of living units: — Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK El Type/Mfg Capacity— No. Compartments PKG. TREATMENT PLT. L1 Method of Disposal Distance to nearest: Well Foundation— Property Line LEACHING LINE L-I No. & Length of lines Total length/size FILTER BED El Distance to nearest: Well Foundation— Property Line SEEPAGE PITS I I Depth Size Number SUMPS 11 Distance to nearest: Well Foundation— Property Line DISPOSAL PONDS El 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."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 equired inspections. Complete drawing on reverse side. Signed .4";Y'l ALomd Title: 60,0160" Date: tic. FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit oc/Groutjnspection-by, Date Final Inspection by Date Additional Comments: 0 Stk 466-6781 El Lodi 369-3621 0 Manteca 823-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT UE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CASH EH 13-24(REV.I/H 5) EH 14-26