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I APPLICATION FOR PERMIT k SAN JOAQUIN LOCAL:HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA I Telep146he(209)'466-67$1 PERMIT EXPIRES 1 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 Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health 6'strict. ,. Job Address City ArFiYCq ' Lot Size_S Age&." PM Owner's N. i 1 --?a ue Address =/99 7~111Viu ��E �I. �ALL/�C �+CJIC Phone 7-82131 Contractor_1��RRlifl N sAddress .f9. License No,2 M43 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑: DISTANCE TO!�NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE —� h FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDEDIJUSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ._ El Industrial '( D,Open Bottom{ ❑ Manteca -'Dia. of Well Excavation ' F r Dia. of Well Casing �- � I- < .. 9 ❑ -Domestic/Private ❑ Gravel Pack 1-1 Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seale Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done j Well Destruction ❑ Well Diameter Sealing Material (top 501 4 I Depth Filler Material (Below 501 + ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ■ DESTRUCTION ❑ iNo septic system permitted if public sewer is j available within 200 feet.) k4:1 -(L Installation will serve: Residence X Commercial_ Other ; t Number of living units: 11 Number of bedrooms 2 `_ � �-» -_--- - - ---.�,....._.w.,.. ��._..,• Character of soil to a depth of 3 feet: 54AW LoAvVI Water table depth ) SEPTIC TANK ■ Type/Mfg d Capacity 7 00 ._ No. Compartments rj PKG. TREATMENT PLT. q Method of Disposal Distance to nearest: Well Foundation ... Property Line .S'O LEACHING LINE 0 No. & Length of lines C� Total length/size 190 FILTER BED ❑ Distance to nearest: Well__Sm Foundation OO Property Line�_ . I SEEPAGE PITS ❑ Depth Size X 10 X OWLrnb,r r SUMPS ■ Distance to nearest: Well 9 0 _ Foundation 4 6.0 Property Line ZC�)/,, y„ ...: . DISPOSAL PONDS ❑ 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. {r Home owner orilicensed 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 E cert as 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- tioi� ws of California." f Thea t nt`must ca for al required i pectin Complete drawing4RNr^ se side. Y f # r Si tl �� Title: � �" '� Date: t ! FOR DEPAT US NLY "("1( T r Application Acc opted by tArea Date '` r w �L�O i - t. l Pit Grout inspection by Date_ t{-226 Final Inspection by Q� a�+. .pste Adm d tibnel Comments: j M ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ! Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,IStk., CA 95207 ; � r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE.... ..,..__.,PERMIT='N0. INFO CASH I + EH13-24 1REV.t./•as},�,' ,,,, w,.,,,,c _ EH 1426