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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.-HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED 7 (Complete in- Triplicate) s Application is hereby made to the San Joaquin LocalHealth District for a permit to construct and/or install the work herein described. This application is 1�1made 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 X 21 S 1 / 113%4M_Z7 R,D. _ City 40,l7/ Lot Size 6SS__'eK 33 y_ PM Owner's Name d! E Et/ Address S to►.••1..E PhoneeZo Contractor 1�f--e5 Address3YCO C. 1-FW, 411 (0 License No. Phone TYPE OF WELL/PUMP: NEW.WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' DISTANCE TO NEAREST.: SEPTIC TANK.,_' SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION; AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE;;,t TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industriah, _ ❑.Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑#Gravel Pack El Tracy Type of Casing Specifications 1-1 Public F1 Other 71 Delta Depth of Grout Seal Type of Grout - I I Irrigation __.Approx: Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction C Well Diameter Sealing Material atop 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is " available within 200 feet.) Installation will`serve: Residence Gommercial_ Other -' -L Number of living units:._ Numbef_of bed"rooms Character of soil to a depth of 3 feet:=.,-,_C ��/ C_4-,9-PLF�/4' Water table depth 74-1 `ASEPTIC--TANK ` FType/Mfg, -C-}ST L Capacity/ZA90 No. Compartments i �- PKG TREATMENT PLT, '~_/rf Method of Disposal N . Distance to neardt: Well foundation Property Line ' t + LEACHING LINE .No. &-Length of-lines..C?-).-aX _ t Total length/size f r FILTER BED ❑ Distance to nearest: Well 1��^-' Foundation /r�� A Property Line 3O r y u T SEEPAGE PITS Depth ��' Size .'33"'-V,ArA .—'"""''Number �— SUMPS Ll Distance'to-nearest:—+Well 2496 2 Foundation .Tor Property Line 3 d' 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, an rules and regulations of the San Joaquin Local Health DFstiict. Home owner or licensed agent's signature certifies the followind: '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 ties!certifies the,following:"`I certify that in the performance of the work for which this permit is'issued,.i sh`ali employ persons subjebt to workman's compensa- "tion laws of,California." t The applicant m� t call for alt req 'ed i ctions. Complete drawing on reverse side. Signed X Title: 4l Date: �c FOR DEPARTMENT USE ONLY A plication Accepted by Date U�a7 Area P or Grout Inspection by ate i . Final Inspection b Dat)- J � Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE s AMOUNT REMITTED C K H RECEIVED BY DATE PERMIT-NO. a.Y _ �rw.•-arm® r -4-0" .�� eee - _�. - } k +.EH 1 3-24 tREY.t/H 51 ---�..-•,.��-.,.�� 1 ` f ` EH 14 26 ;l.'l:�