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` %001 APPLICATION FOR PERMIT err/ 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) V 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. C/ 1 Job Address l(J/ $ / )SO ` y b�e--��s�7 City //� Ory( 1Lot Size /© AC/f�Z PM LOwner's Name/I 71 M Os� _�/ Address /_9 Z iY/!9 WI. 1 a 4 LpC�ca— Phone� —1 s� Contractor CYgte D"11W CO, Address an O &W7 T'r1/'f - License No, phone '— L TYPE OF WELL/PUMP: NEW WELL-J4. WELL REPLACEMENT ❑ 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 WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing LDomestic/Private KGTaveI Pack ❑ Tracy Type of Casing rV C_ Specifications Ch!u 161,M Public r F1Other FIDelta Depth of Grout Seal 106 / Type of Grout HP-9 b CCv e" _ I I Irrigation pprox. DepthI I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump.z,a�ee H.P. 3 State Work Done L Well Destruction ElWell Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residenca_ Commercial_ Other Number of living units: Number of bedrooms - f Character of soil to a depth of 3 feet: Water table depth D SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ z Method of Disposal - f� Distance.to nearest: Well Foundation �� Property Line \ LEACHING.LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foun`,dation Property Line L � T SEEPAGE PITS I I Depth Size Number l SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 I hereby certify that I have prepared this application and that the work will be done,an.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,1 shall employ persons subject to workman's compensa- L tion laws of California." The applic st call for all requiredin/syp¢ctioni Complete drawing on reverse side. - Signed X� ./ �G�"^ Title: .0-9c[,,t,10, Data: 7— Z4—.Pe_ FOR DEPARTMENT USE ONLY fff Application Accepted by Date 1�Z--1�' TT Area 0 _ t Pit or Grout Inspection byJ Date Final Inspection by ,Izzi- Date _497/9'45' (� Additional Comments: ❑ 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"'^' c.r, re osoni !1,W PLATE 11, Page 7 of 16 INFO AM10UNT DUE A{{{MOU/NT REMITTED nCASH RECEIVED By DATE PERMIT'NO. v ` EH 11 y9IREV.1/P51