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`p APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. 1$62 for well/pump and the Rules and Regulations of the San Joaquin V Local Health District. ' K�-/,�-/ Job Address �i95T YV�ST /�/Pct/ RSD City 41�� PM Lot Size -r lD �G I /7v/D /1 5 Address A� 6k ��33ly Phone 599 ® Owner's Name T7VEGoPM—/"f",��5�/� �.4ST Y4 /YIl T� 14AE,, ,, Contractor S19LS Address Nl�/✓T�� 1L/� License No.�� U�ZPhane '&'L3'3 / $ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS tt( ❑ Industrial ❑ Open Bottom 11 Manteca Dia. of Well Excavation 1?1 ofAe"tP l ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications - t f'1 Public f 1 Other ❑ Delta Depth of Grout Seal r Tpe of Grout I I I irrigation —Approx.'Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P- State Work Done_ Well Destruction LJWell Diameter Sealing Material [top 50') NVIRQr� f Depth 1 �,4 Filler Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION I' REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence I—,,, Commercial_ Other Number of living units: / Number of bedrooms -1 @ t Character of soil to a depth of 3 feet:f L.D A// Water table depth G SEPTIC TANK ❑ Type/Mfg .SE I L Capacityf� 12 No. Compartments PKG. TREATMENT PLT. E3 � G eanlGR�T� f° �'G Method of Disposal Distance to nearest: Well l�d Foundation 2� Property Line /404 LEACHING LINE P--'No. & Length of lines X"-- i _ • Total length/size FILTE RFD ©"'Distance to nearest_ Well /949 Foundation��O Property Line !� SEEPAGE PITS /Y )O- 1 I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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,t shall employ persons subject to workman's compensa tion laws of California." ThAapplicant ll fo IIrequir I spections. C plate drawing on reverse side. C,�SiTitle: `�/tZ/f T4/� Date: I2 `� I 0A DE TMWT USE ONLY Application Accepted by ! Date 'IJ�.V Area i Pit or Grout Inspection by /' Date Final Inspection by ate Additional Comments: / 71 z - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C K R RECEIVED BY DATE PERMIT'NO. INFO 11 ♦.EH1 3-241REV.1/mtO I Q d O EH 10-28 l