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I APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (2091 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 descrined 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 . IRA Ar- PM-- o 5736 /CLU S_ AyE�T C Y City (-�— Lot Size - Job Address _ (� C C r2 Owner's Name _ r LL 1 fI tM l ��Address I 7,{0 K/T AJS AdJress Irk-r�1 N8S !f '- Ef eclLFicense No. ContractorC • . TYPE - _ OF WELL/PUMP r NEW WELL C WELL REPLACEMENT -1 DESTRUCTION i7 PUMP INSTALLATION'--,---- `SYSTEM REPAIR ❑^ - OTHER'n DISTANCE TO NEAREST: SEPTIC TANK __.— SEWER LINES .-. . _-- DISPOSAL FLD.- PROP. LINE FOUNDATION - AGRICULTURE WELL --.- OTHER WELL__ PITS/SUMPS ---- 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS G Industrial G Open Bottom 7 Manteca Dia of Well Excavation Dia. of Well Casing . Specifications � U Domestic/Private fl Type of Casin4— :J ------ Gravel Pack Tracy - 1.1 Public 1.1 Other, CT Delta Depth of Grout Seal Type of Grout I i Imilation __- Approx. Depth I I Eastern Surface Seal Installed by --- ---- Repair Work Done 1l Type of Pump•__ H.P. "-. __ State Work Done _ Well Destruction ❑ Well Diameter Seating Material (top 50'1 r Depth Filter Material (Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRfADDITION I I DESTRUCTION I I enveilablre within system permitted if Ail+ sewer is J � Installation will serve: Residence Y Commercial _ Other _ r Number of living units: -_- Number of bedrooms �_� ) QI y Character of soil to a depth of 3 feat. Alli R F L rQtil n�4&VA _ _Water table depth SEPTIC TANK ❑ Type/Mfg ' _____ f _ _ Capacity 200,0- I!2� No. Compartments - w PKG TREATMENT PLT. Ll `f f� I Method of Disposal Distancetonearest:' Wall�;�QfFoundation __ •_ Property Line -- ' - Total tength/size. LEACHING LINE O No & Length o4 Goes _ . . �-' �_ - ation /a ___-_ Property Line FILTER BED ❑ Distance to nearetit: Well Found . - SEEPAGE PITSI : Depth r Size .---- ,,I--_--- --- -__ Number - -�--- il SUMPS I6 Distance to nearest: Well lea - Foundation _ P(roperty Line 40 I ( DISPOSAL PONDS a I hereby tartly 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 regulatrons of the San Joaquin Local Health Di3trlct. 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 workmans compensation taws of California-Contractor's hiring or sub contracting signature cert-ties the tollowrng: "I certify that it)the performance of the work for which Llys permit's issued,1 shalt employ persons subiect to workman's eompensa- tion taws of Cal forvia-" The app ie t mu call f red in:p -ns. Complete drawing or,reverse side. ' Signed Title: _ Date: FOR DEPARTMENT USE ONLY Area Application Accepted by ... _ Pit or Grout Inspection by ! _ _.__._. Da�t/o� Fina Inspocton Cy Date Additional Comments: teca 1 S 104 -----` O Stk 466M1 C Lodi 369-3621 D Manteca 8237104 C Tracy 835 6-85 I Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 CK 9` FEE AMOUNT DUE AMOUNT REMITTED CASPI RECEIVED BY DATE EWT-NO. INFO �(� n.iN1341 tREVU U'•' � " 1 EH 14-I6 1