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tl APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKT'ON, CA Telephone (209) 466-6781 L (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.99 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 2251 Hollenbeck RoAdCity StP-C-kton—_ Lot Size 3 acres PM Owner's Name Union Safe,-Ue OSit Bank Address -a2_7-Ya3Y----Main.._� - x_ Phone 946-5178 f;;A.ra,ti -- Contracto'r s Name .. Jerry Joy & ASsociate6cense No. Phone �h2�4 " TYPE OF WELL/PUMP: NEW WELL ❑ VY'E1 L REPLACEMENT C:-i DESTRUCTION ❑ - PUMP INSTALLATION ❑ SYS�"_M REPAIR ❑ OTHER C:: DISTANCE TO NEAREST: SEPTIC TANK .SEWER LIN::s —.DISPOSAL, FLD._--._— PROP. LINE FOUNDATION AGRICULTURE WELL _T. _ OTHER. WELL_—_.PiT,,,sumps _ 'INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS_ ✓-1 industrial ❑ Open Bottom ❑ Manteca Dia. ai Well Excavation —�.�. Dia.'of.Well Casing _ _ o0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type e of Casing-.----—__ ` Specifications L Public ❑ Other ❑ Delta Depth of Grotlt Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by_ �_�—. Repair Work Done ❑ Type of Pump H,P. —= ___-_ State Work-Done _ # Well Destruction ❑ Well Diameter Sealing Material(top 50') __— Depth ' Filler Material [below 501 _ ___ _ _•` _ TYPE OF"SEPTIC WORK: NEW INSTALLATIONX0 REPAIR/ADDITION it DESTRUCTION ❑ (N6-septic systemp,.!,jjiitted if public sewer is .•. :i available within 200 feet.) :"Installation will serve: Residence Xx Commercial_ Other Number of living units: 1 Number of bedrooms Character of soil to a depth of 3 feet adober 50 t -I- ------- ----- __Water table depth--- SEPTIC TANK gX TypelMfg Concrete _Capacity 1200 — —No. Compartments Two - PKG. TREATMENT PLT. ❑ + Method of Disposal Distance to nearest: Well Foundation---- Property Line LEACHING LINE ®X No. & Length of lines ._ Two (2) — �' Total leng0l;,">o-__S FILTER BED ❑ Distance to nearest: Well—_.?�� FoundationProperty Line SEEPAGE PITS _ . 622 Depth —2 5�� Size__ 33' _ w� Number.—ZW"2)- SUMPS ❑ .Distance to nearest: Well 4.Q_ Foundation Property Line- 30 DISPOSAL PONDS ❑ - I hereby certify that I have piepared 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 required ins p ctions. Complete drawing on r9ey6r side. 1 Signed X._—_. Title: — Date: FOR DEPARTMENT USE ONLY 1 e� Application Accepted by - Date_-1 �--z i Area P ® Pit or Grout Inspection by Y'-'"Date �a-lZ-'`J�� FinaE Inspection by- a3`t,d...VA&.V& Data Additional Comments: - ❑ Stk 466-6787 El Lodi 369-362? ❑ Manteca 823-7104 El Tracy 835- Applicant 35 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. EH 13.24(REV.101831 EH 54-26 r l Cwt- ,ii 4-►�z�