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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 11 tereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is ,liance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin District. ss �! I�/ L1�(_�� zPOv.� Jrty L O /l/• Lot Size S 2 /!G- PM Name VrinA/LJ05 /ao(J X Address ;2!1 95j,PkSllfrrr„ S?/C Phone 0,3 actor's Name L'/J C C o u S T IA"(– License No. � y2�3��i 30/ Phone e OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r� 1 STANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 1_" r 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 ❑ Other ❑ Delta Depth of Grout Seal ^ 13Irrigation Type of Grout ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') 9999q�2 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1 r Installation will serve: Residence— Commercial— Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK Water table depth .✓�' Type/Mfg okw 5. ,-s C�.+Gf+v✓$apacitd-I PKG. TREATMENT PLT. ElNo. Compartments !!'�� a�... Method of Disposal Distance to nearest: Well�� Foundation AP ,f Property Line LEACHING LINE S} No. & Length of lines 2^ Total length/size �� O FILTER BED ❑ Distance to nearest: WellALO Foundation/o f Property Line SEEPAGE PITS ,Irk Depth Size 33'x:2S Number `0— SUMPS ❑ Distance to nearest: Well/sem Foundation /0 .f- Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenm- tion laws of California." The applica +(Aust call jor requirerrnspect. sy� plate drawing on reverse side. Signed X�_��2x!/// bf Title: 6?f'/$S /L/_ C C o.uS Data: _ 3—al— FOR FOR DEPARTMENT USE ONLY p06:— Application Accepted by ` /: Vd-tip_ -� Date J F reaPit gr Grout Inspection by " Final Inspection bYDate Additional Comments: ❑ Stk 468-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354385 Applicant- Return all opie to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK a - INFO CASH RECEIVED BV DATE PERMIT NO. ia2.IREv. ,aiaal –�OS 428