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C f APPLICATION FOR PERMIT SAN .JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCK.TON, 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 end/or Install[F.e work herein described.This application is made in compliance with Snn Joaquin County Ordinance No.519 for sewage or No.1862 for well/pump and the Rules End Regulations of the San Joaquin QL�to� Local Hmlth District. 40;p- 0-1=��r Job Address �^n .s � 99 City S;�&6Z_�'�'Lot [�Sa. etC_�eS PM Owner's Name VALtY n/.Ji OI �.�Address �'t•f/�_ '�•MAv�I�]��lf[y�ta5a_ Phone Contractor'.,Name EfQjiD G .6t70s�_ License No. �3ICYJfa— Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR U OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD._ PROP, LINE FOUNDATION AGRICULTURE WELL _ OTHER WELL—_ PITS/SUMPS 14 INTENDED USETYPEOFWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑Industrial C Open Bottom ❑Manteca Dia.of Well Excavation Dia. of Wall Casing ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing_ Specifications ❑Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout .— ED Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by v\ Repair Work Done C Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Caaling Material(top 509 Depth Filler Material(Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION a (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence z Commercial_ Other Number of living units:—L Number of bedrooms Character of soil to a depth 13 feet: I ' � Water table depth SEPTIC TANK depth A0yi CapacityJkPo No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal DiS;.nce to nearest: Well Foundation Property Line 2-Iftfl LEACHING LINE No. 8 Length of lines SQA Total length/size /ADX ]L/ FILTER BED ❑ Distance to nearest: Well 6LIV Foundation 2-Cx Property Line /04 SEEPAGE PITS A Depth �C' tEe l ry _ Number ` i i SUMPS ElDistanceto rearest Well Foundation Z� Property Line �O9 DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the pork will be done in accordance with San Joaquin county ordinances,state Tawe, and rubs and regulations of the San Joaquin Local Health District. '^ Home ownar or licensed agent's signature cenif es the following:"I certify that in the performance of the work for which this Permit is issued. I shall not employ any person m such manner as to become subject to workman's compensation caws of California."Contractor's hiring or sub�contracong signature certifies the following:•'I certify that in the performance o".the work for which this permit is issued,I shall employ persons subject to workman's compensa. tion Jews of California." The applicant must call/lot all peaions. C date d-awing on rev se side- Signed 1 Signed X._(�y("otTitle:fJ� y1-O— Date: /— —A4 FOR DEPARTMENT USE ONLY APplra[io in Accoplad by S.�`f.Gs.._-�.— ` t e. _ _ Oata_ 1'11' Area p it or Grout Inspection by Q Date 1'tt'4�_Final Inspection by— Additional y Additional Comments: — ❑ SIT, 466-Ml ❑ Lodi 369.3621 ❑ Manteca 807104 ❑Tracy 6156395 Applicant- Retum all copies to: Environmental Health Permh/Servicas 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 55201 FEE AMOUNT DUE AMOUNT REMITTED CASH AFf.EIVED BY DATE PERMrt NO. INFO .Eu fn