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APPLICATION FOR PERMIT . SAN JOA(IUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES i 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 Jua(tuin Cnunty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ,1 p Job Address _.TJ�i1SG_" o� �U�! �/�. —. City LZb� Lot Size 5 I�« S PM M DVEL.O�ME E4 X { -r !/IJC{�O/l�Phane .... �Z�_� ._...._ Owner's Name _-.-_�r-_ Address 1 Contractor SMS 2F—y_r_— ,P/t'twT_ Address �s5 I�G�TD icense r4o. 5..__ 57 I Phone Q 41 _C?.4 TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION 0 PUMP INSTALLATION ❑ SYSTEM REPAIR Cl f 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 CIJI Industrial s. Open Bottom Fl Manteca Dia. of Well Excavation_ —__— Dia. of Well Casing FI Domesticl Private i [..l,Gravel Pack LI Tracy Type of Casing Specifications I'I Public p 1 1 Other I'1 Delta Depth of Grottl SeatType of Grout I I In4lation ___ Approx. 0pth I I Eastern Surface Seal Installed by Repair Work Done l_7 Type of Pump. H.P. _—__-_ State Work Done _---� Well Destruction ❑ Well Diameter —_—__ Sealing Material (top 50'I — — Depth '# Filler Materia! Welow 601 --- _ TYPE OF SEPTIC WORK; NEW INSTALLATION tIFPAIR/Af)[IITION I I DESTRUCTION I 1 INo septic system permitted if puhtic sewer is I available within 200 feet.) Installation will serve: ResidenceCommercial ____ Other Number of living units: "r f Numbers of bedrooms Character of soil to a depth of 3 feat: h c!/~+ Water table dept p;" A- SEPTIC TANK Type/Mfg +__CbµC-'LE� ": ' Capacity _ G t-'N6."-Carrtpartments PKG. TREATMENT PLT. Cl 1 t ' Method of Disposal oral r Distance to nearest: Well_1_ _ Foundation Property Line — r01 't 60 _ - LEACHING LINE F No. & Length of lines — Total length/size. -- FILTER BED 1.1 Distance to nearest: Wel! Foundation 30 Property Line __ rI ',' SEEPAGE PITS )4, Depth '� ET, Size—; r< �. "'rmber i -- T---.�._ f SUMPS L! Distance to,nearest: Well I_. _' Foundation, -° Property Line A DISPOSAL PONDS C7 t 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 Diktrict. Horne 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." Contractors hiring or sub-contracting signature certifies the following: "I certify that in theperformance of a work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant mu r all r i spections, pieta drawing on reverse side. Signed X Title: l�2 �� Data: FOR DEPARTMENT USE ONLY ILI Application Accepted by _.___ Date 1 Area Pit or Grout Inspection by Date �inl Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl Manteca 823-7104 © Tracy 835-6385 Applicant-.Return all copies to: Environmental Health Permit/Services 16D1 E. Hazehon Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNTjDU�E AMOUNTREMITTED ��A�sljf RECEIVED QY OAf7E P�fEHMIT�NO. r.EH13711REY.tin5Y (.1 70 /�' FH 11.78 --