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r• APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1/ �a 149' _75— (Complete in Triplicate) Application is here made to the San Joaquin L cal 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. f— Job Address dCCS M6riF/-/– ke City Rip &-n Lot Size PM Owner's Name �ff:lv;92j2l ., Address a hone Contractor's • / � �^ Contractor's Name P1-.Xr-..,9 License No. L�W, 5`1—3 Phone TYPE OF WELL/PUMP: N WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION I SYSTEM REP IR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 68 SEWER LINES � DISPOSAL FLD.oe6 Q PROP. LINE LQG�/ 1v FOUNDATION a�LS 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 G K.Domestic/Private AGravei Pack ❑ Tracy Type of CasingJovC- Specifications t^1aJ 5 /6o ❑ Public //❑ Other ❑ Delta Depth of Grout Seal 0 f Type of Grout a F s� ❑ Irrigation /CsJ4pprox. Depth ❑ Eastern Surface Seal Installed by. Repair Work Done ❑ Type of Pump S1-6 H.P. � State Work Done Well Destruction Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) �� Installation will serve: Residence_ Commercial_ Other 6 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments p� PKG. TREATMENT PLT. ❑ Method of Disposal L Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Z Foundation Property Line DISPOSAL PONDS Q 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, 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 rail for all requir inspections. Complete drawing on reverse side. /�y 5 Signed Title: r Date: 4 r' 8 s FOR EPARTMENT USE ONLY �r fir/ -- — S_ D Application Accepted by � _DateD � � Area Pit or Grout Inspection b Date ✓ S Final Inspection by pate •—�� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Flealith Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DYE AMOUNT REMITTED A RECEIVED BY DATE PERMIT N0. + EH 13.24(REV.10183) ](v � 19_ - g57-q3� a- CJ yQ EH 1126 V