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£ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT x 1601 E. HAZEL T ON'AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES VYEAR 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 A.J City E Lot Size PM ,,��cc� �?'J Owner's Name �tAddress r" ` '-7--�--�-� Phone Contractor4L n Address F-?V License No.Zlf Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f * PUMP INSTA1_-L-A-TION ❑ SYSTEM REPAIR 0,.- DISTANCE TO NEAREST SEPTIC TANK'_� OTHER ❑ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHERWELL PITS/SUMPS INTENDED USE _ .TYPE-OE-WELL PROBLEM AREA 1CONSTRUCTION_SPECIFfCAT10NS ' ~` Cl Industria! ❑ Open Bottom ❑ Manteca pia- of Well Excavation --I- 0 ❑ Domestic/Private ❑ Grave! Pack Dia. of Well Casing 3 ❑ Tracy Type of Casing ? I f'l Public it Specifications d ' ❑ Other Cl Delta ° " Depth of Grout Seal I I Irrigation Type of'Grout g- —,-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump I H p - State Work Done Well Destruction ❑ Wall Diameter Sealinglateriaf hop 501 Depth I Filler lllfaterial IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I f DESTRUCTION 1 },INo'septii system permitted if public"sewer is a y O Installation will serve: Residence available within 200 feet.! 1 ' commercial Other l Number of living units; Number 9f bedroorrls + °1 ' h I I - Character of soil to a depth of 3 feet: t/ SEPTIC TANKWater table depth 4 I ❑ Type/Mfg - Capacity 4 �504 No. Compartments` I PKG. TREATMENT PLT. ❑ r `77;., Method of Disposal y Distance to nearest: 'lh/ell jCJ Foundat on` Property Line LEACHING LINE No. & Length of lines '7` � Total length/size � FILTER BED ❑ Distance to nearest: Well � —� Foundation �/`� Property Line SEEPAGE}PITS I I Depth — Size 7J Number „' :i BLIMPS Distance to nearest: Well �T Y r t Foundation 9 6 r DISPOSAL PONDS ❑'. ' :Property Lined A „ I hereby certify that t have prepared this application.and.that-the-work-will-be-done-in-accordance-with San Joaquin county ordinances, state favus and P. rules and regulations of the San Joaquin Local Health DT§trict. -1 'I. f} Hoitle.owner or licensed agent's signature certifies the following: f .employti�ny person in such manner as to become subject to wo kmah's compensation lfy that in the aws ofCalifornia." Co rk for o whithiring opsub-co issuen Is hnalfn6t" ormance of the wo certifi6kJbe`followrng I certify fhafin the pefto�mance of the woWfor which this permit is`issued,I shall em to g g tion laws of Califgrnja ''�* , r / P y persons subject to workman's cdmpensa- r 'The applicanf t mu t call+for al required 'nspections. Complete drawing on reverse side. Signed Xu Date-.`�rt .0 o�- r r : OR,.D ARTMENT USE 0' Y �. i F 'ApPr Ickion Accepted by _ a i+ L r Date U Area 9 F Pit oY Grout Inspection by _ + Date Fi al`Jnspection by Date ,A dditional*Comments: iF/� °�' ',a y ; /� }❑ Stk 466-6781 LJ 100d! 3693621 ❑ Manteca-�a23 104 J835-6385 `^ 0:Tr 835 6385 j Applicant- Return all copies"to: Environmental Health Permit/Services 1601 E. He,7elton Ave:, P.O. Box 2009, Sik CA_95201 FEE - AM i INFO OUNT DUE AMOUNT REMITTED CK CASH �- RECEIVED 6Y DATE PERMIT-NO. «+.EH 13-24(REV.-1/X5)