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CPA Z APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 36000 WA15 5CIAe Al 14o7-l-K YT v 666, City ZZ .C,le_ Lot Size -g a X 10 0 PM Owner's Name G ��'ri Address S.*/nG Phone 836 Contractor's Name —, AoVr4V&_ SvN License No. y y` Qf Phone ✓rte 'y� 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 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done U) I ' Wel(.Destruction ❑ Well Diameter Sealing Material (top 501 0 Depth Filler Material (Below 501 0 TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION X DESTRUCTION ❑ (No septic system permitted if public sewer is G available within 200 feet.) Installation will serve: Residence_,X_ Commercial_ Other Number of living units:—L Number of bedrooms Character of soil to a depth of 3 feet:—q L 00Pirr Water table depth X S� SEPTIC TANK f8 Type/Mfg Cyt' C.gs.7 Capacity /-4 10 No. Compartments � PKG. TREATMENT PLT. ❑ Method of Disposal 0 Distance to nearest: Well Foundation /01' Property Line A-42' 3 LEACHING LINE ❑ No. &Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r' SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 9 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 inspections. Complete drawing on reverse side. Signed XTitle: Date: / FOR DEPARTMENT USE ONLY Application Accepted by W I Date Area —? -- Pit or Grout Inspection by Date Final Inspection by ' Date Additional Comments: & ^ Q/fl I — 411 ❑ Stk 4664781 ❑ odi 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 IFEE NFO AMOUNT DUE' AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMITA`NO. + (REV.10/831 EH W28 �� `�Z`< s5�3�.