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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (200) 466-6781 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 coratruct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1852 for well/pump and the Rubs and Regulations of the San Joaquin Local Health District. Job Address � a �r ��'a�`L-�1 ..~ City LO-A f Lot Size_ PM Owner's Name &I ( EAL Vi MF E,, Address 00 Re � r`M "-bT Phone _�a S Contractor L��} _ f fY{� ddress 35� License No. b8'a Phone /d�s� TYPE OF WELL/PUMP: NEW WELL ❑ WELLREPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ /SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELLI r PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public /O Other ❑ Delta Depth of Grout Seal Type of Grout T O-Inigation_ J/ —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work_Odne ❑ Type of Pump�- - H.P. State Work Done l Well Destruction -0 Well-Oizmeter -- --Sealing Material(top 501 Ali n F Depth Fille�lMaterial(Below 50'1 TYPE OF SEPTIC WORK:_NEW INSTALLATION_ REPAIR/ADDITION ❑ DESTRUCTION O (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Resid nce .�Commercial�-7_.Other \ Number of living units:77 Number of bedrr Mrs a.� 7 Character df soil to-mi depth of 3 feet:" ") rr,�'�IA% '� Water table depth � h IF, _ SEPTIC TANK fype/Mig Cnk1 c *bA Capacity 1&P1C� No. Compartments PKG.-TREATMENT PLT.❑ —1I I 1 Method of Disposal 11 '21. i C Distance to nearest: Well Foundation ACL Property Line LEACHING LINE `ni.--Ala. & Length of lines /�^ Total length/size FILTER BED ~ Cd—Distnnce to nearest: Well—/--t�i.i�— Foundation —510 Property Line ( /� SEEPAGE PITS h on Size 3 Number 0 Dista �) SUMPS Distance to nearest: Well Faunde[' __;dS_00 Property Line DISPOSAL PONDS ❑ t Y I hereby certify that I have prepared this application andthatthe work will be done in accordance with San Joaquin county ordinances, state lam, and rules and regulations of the San Joaquin Local Health DistdcK�J 'r NV Home owner or licensed agent's signature cert'dies,the following: "I certiN that in the performance of the work for which this permit is issued, 1 shall not E employ any person in such manner as to become`-bubject to workman's compensation taws of California." Contractor's hiring or subcontracting signature cert'rfr following:"I rtify that in the pEirforniance of the work far which this permit re issued,1 shall employ persons subject to workman's compervi tion laws o litornia." Th applican mu call for al aqui dins tions. m e drawing on r arse si Signed Title:00 Date: OR DEPARTMEN USE ONLY �� Application Accepted by Date Area Pit or Grout Inspection by Data ZI Inspection by �'+� Data � Additional Comments: U 1 ( wu of— EI Stk 465-8781 Lodi 1 ❑ Manteca 82@hIO4 ❑ Tracy 835-6385 Applicant• Return all c as to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 V. FEE AMOUNT DUE AMOUNT REMITTED f CASH j C RECEIVED BY DATE PERMIT'NO. �'.,. INFO -(),1 �y� �I�/ (�I///1 G f� ��Y /M i t�r� EN I3RE IPEV.l,e51 f�.0 S l /s V% I l((j()A7 & l/V ! 7.r KS EN 14]e