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\/ APPLICATION FOR PERMIT _,/ SAN JOAauIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. I•. Job Address 11134 S. J QG ne. gcL. City Lot Size dol !p Acr PM +- 34—S Owner's Name +n 1110512—h e—&; Address SQ.rne Phone ` Contractor SC 1� Address .5a_M Pi License No. 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 FOUNDATION AGRICULTURE WELL OTHER WELD PITS/SUMPS _ LINTENDED 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 F1 Other n Delta Depth of Grout Seal Type of Grout_. I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. _ State Work Done_ ...! Well Destruction ❑ Well Diameter Sealing Material (top 501 -->, b Depth Filler Material (Below 501 IN TYPE OF SEPTIC WORK: NEW INSTALLATION)q REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence `)[!' Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ScL-n Water table depth 27 �, SEPTIC TANK !( Type/Mfg � d- L Capacity-1600iNo. Compartments • PKG. TREATMENT PLT.11 / / Method of Disposal L L Distance to nearest: Well—116 Foundation Property Line A 13 F LEACHING LINE 17( No. & Length of lines , Total length/size FILTER BED ❑ Distance to nearest: Well��Ir Foundation Property Line C SEEPAGE PITS 11 Depth Size Number /a SUMPS D Distance to nearest: Well Foundation Property Line \, DISPOSAL PONDS ❑ 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 and regulations of the San Joaquin Local Health Di3trict. 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, 1 shall notes. 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 compensa- tion laws of California." The applica`n�/!/yst call for all required ins p ctions. Complete drawing on reverse side. c.�7 Signed X_ nnTitle: oco V1 L le Date: ,—;1— ` (y�\ FOR DEPARTMENT USE ONLY Application Accepted by DDate Z—✓272 Area Pit or Grout Inspection by Date ,Final Inspection b ' , / Date y L� Additional Comments: PLATE 11, Page 8 of 16 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 el L FEE IN AMOUNT DUE AMOUNT REMITTED CK 0 CASH REECE��1IV///ED BY DATE PERMIT NO. LEEH M21 H t4391REV.l/x51 �09 -70' �� ] r _3