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APPLICATION FOR PERMITm SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Teiephohe {209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1Complete 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 weit/pump and the Rules and Regulations of the San Joaquin Local Health District. /� Job Address 1 e) t .! F, M UN p Ave.eCity� -�T04N Lot Size �f' Cr F_5 PM —.. Owner's Name RK5'JEVEW-fMEAJT 11JC. Address F&� N55 �; iN4TDrU -46Z- t8 `-, ---_� -�__�___._ .��........ Phone ---....- Contractor M AllEE-WMENT LCAddress 1585.FAP-A-ii m&TcmJLicense No.5�73 PhoneZa-1 ,- TYPE OF WELL/PUMP: NEW WELL C1 WELL REPLACEMENT ❑ DESTRUCTION 0 s PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER ❑ {{ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. __ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL — PtTSISUMPS __ y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation -�_ Dia. of Well Casing ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing _ Specifications FI Public rl Other F1 Delta Depth of Grout Seal Y Type of Grout I I Irrigation _Approx. Depth 1 1 Eastern Surface Seal Installed by __— Repair Work Done 1-1 Type of Pump H.P. State 'Rork Done Well Destruction © Well Diameter Sealing Material Itop 5171 _ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION)4, REPAIR/ADDITION I I DESTRUCTION I I fNo septic system permitted if public sewer is available within 200 feet.) Installation will serve. Residence Commercial -Other_ Number of living units: Number of bedrooms— �t Character of soil to a depth of 3 feet: GL Q� ~_._.... _� —_ Water table depth A ?I?F -�Fr., SEPTIC TANK Type/Mfg L C01VC2�r� Capacity �br70 � No. Compartments _ PKG..TREATMENT PLT.0 l 1 Method of Disposal Distance to nearest: Well _/2 D_ Foundation. 5 Property Line LEACHING LINE �. No. B Length of lines _ 5 fFT _ Total length/size— 170 FILTER BED 0 Distance to nearest: Well VFoundation 4Q_ Property Line— fI 5� SEEPAGE PITS 1 Depth .�15___r.._...,,Stze�.. 33�� _p - Number SUMPS Ll Distance to nearest: Weil? �_ Foundation—Q_— Property Line DISPOSAL PONDS ❑ s I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, sutra laws, anti rules and regulations of the San Joaquin Local Health DRtrict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issa,ed, I shall no; -employ any person in such manner as to become subject to workman's compensation taws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of thin work for which this permit is issued, I shall emptoy persons subject to workman's compensa- tion laws of Califo ia." The applicant t It I aired i ctions. Complete drawing oxn/rrreveerssee side. Signed X Title: _Yr /i¢�iet�71/IIG� --- pate: �9 FOR DEPARTMENT USE ONLY J Application Accepted by Pit or Grout Inspection by Date Final Inspection Additional Comments: � ❑ Stk 466-5781 O Lodi 369-3621 © Manteca 823-7104 © Tracy 635-6385__ Applicant- Return all copies to: Environmental Health Permit/.Services 1601 E. Hazefton Ave„ P.O. Box 2003, Stk., CA 95201 ICH INFO AMOUNT DUE AMOUNT REMITTED GAStf fIF,CFIVE0 BY DATE PERPJWNO. ;.EH13-24f1W.,,ee) '7o-a'� o.o0 1712 Jv-Zo�Sri �r-Zi`gID Ett 14Zp•.