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M APPLICATION FOR PERMIT old to 1- O f I—cLaply SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON; CA Za 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. , Job Address 0 L. City 104,31"0 Lot Size 2046 PM Owner's Name MY'''1"y -F�IIC", Address li,57 S.1) IF ArwAh h 14d& Phone J 63 Contractor _Addressit o •1 _ is e i .t--.z ['�$��l yr1�_(,(f_ License,Not' Phoneya'y60^f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0. DESTRUCTION ❑ PUMP INSTALLATION El _SYSTEM REPAIR ❑ _ _OTHER ❑ _ r —DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' ~� � DISPOSAL FLD. PROP"LINE-� 1 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 0 Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I Isl 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 Seating Material (top 501 3 ' } Depth Filler Material IBelaw 50'1 _ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 I DESTRUCTION I I lNo septic system permitted if public sewer is Iavailable within 200 feet.) Installation will serve: Residence✓ Commercial_ Other Number i f living units: —I-- Number of bedrooms ""• Character of soil to a depth of 3 feet: -0104 JV .� 5 q iy w P � Water table'depth SEPTIC TANK_ f9�Type/Mfg L 0AfC t ie,36=_ Capacity ary No. Compartrrli ents _Z� PKG. TREATMENT PLT. ❑ Method of Disposal 1 Distance to nearest: Well fB / r a *) O � Foundation Property Line � �EACHING LINE LW' No. 8 Length of lines ..J— T o Total length/size a Y! FILTER BED '❑ Distance to nearest: Well Aft*14 - �- z I I� Foundation ��f-'z Property Line .'rd � 'f' ( _ s x: SEEPAGE PITS p1"Depth JA Size__-3./3 �r syNumber - s-.`?- �.Sl1MP.B 1 - ❑ Distance to nearest: Well _ _ Foundation,.., PropertY,Line.., DISPOSAL PONDS ❑ r ��_. , -. 1 •"� - I hereby certify that I have prepared this application and that the work will be clonem accordance with San Joaquin Cbunty ordinances, state laws, and rules and regulations of the San Joaquin Local Health Dj%6i6t"t 1 • I Home owner or licensed agent's signature certifies the.following:"y;l_eertify_that,in.th{ a 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 compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. O ,...p Signed X Vi, � L.�i_ n� �- Tide: Ar 4f e P' s.Date: � d d - FOR DEPARTMENT USE ONLY +7 ''Application Accepted by -__._ :Date �^ !� Area 6Pi r Grout Inspectio at Fiyqnspeefion T 6Tgf r 'Date Additional Comments: 0 Stk 466-6781 0 Lodi 389-3621 O Manteca•82&7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY ` GATE PERMIT N0. a.EH 13-24 IREV.1/xbl - sX�` �, --39--3EH 1424 J /l)C"1