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CVA AA APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 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 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 Rules and Regulations of the San Joaquin Local Health District. l J� /� Job Address /3� ,t/•+1JlH% l� JG L �J! AJ /Q5. ` — ,.._ City �J Lot Size PM Owner Name �C�/ 1�5©/�1 l� �,. .05 7�7A) /'/ 14 q`�,� Z 3 Address,, PP `' Pjm Contractor s Aftes Al lf01L-5afca' WA-/ cerise Ph � License NoZS. one TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 11: PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i IM FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL 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 LJOther ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth D Eastern Surface Seal Installed by i Repairl�Work Done ❑ Type of Pump H.P. State Work Done Well D.astruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') C' TYPE OF SEPTIC WORK: NEW INSTALLATION —REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence X' Commercial_ Other .p: Number of living units:—/— Number of bedrooms i Cha rE cter of soil to a depth of 3 feet: Water table depth SEPTIC TANK V Type/Mfg ,*1S Capacity�Z d No. Compartments PKG. TREATMENT PLT. Ll i Method of Disposal FDistance to nearest: Well -.5-0 Foundation Property Line LEACI4 NG LINE ❑ No. & Length of lines 0 Total length/size 2©� FILTER BED ❑ Distance to nearest: Welles Foundation ltd,` Property Line 5- / SEEPAGE PITS ❑ Depth Z—S- Size Number SUMPS ❑ Distance to nearest: Well , Foundation Property Line r DISPOSAL PONDS ❑ 90 k 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 avid regulations of the San Joaquin Local Health District. 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."Contractor's hiring or sub-contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Califia." The a i)licant ust call all re a ns pP pe ions. Complete drawing on reve side. - [ ` I Signedl Title: [:-- 1 Date: / ` FO DEPARTMENT USE ONLY Application Accepted by Date Area V� ' Pit or `T`rout Inspection by Nk- Data �1'�C Final Inspection by Date Additional Comments: ❑ Stk`1:466-6781 ❑ Lodi 369-3621 ❑ Manteca 873-7104 ❑ Tracy 835-6385 I Applicq t- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201