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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone 1209) 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. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address _ _ 3 ku.- 092/ ____._. City &--40 1 Lot Size PM • Owner's Name �` Address Phone U , _ Contracts/-_" ' `� _ _ Andress /•o`'+�'� �'>'3C�'/°`.► "t° License 110,3-12-4-2 SL._.___...Phone 's�J TYPE OF WELL/PUMP: NEW WELL E3 WELL REPLACEMENT 0 DESTRUCTION 0 PUMP INSTALLATION D SYSTEM REPAIR 0 OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLD._ PROP. LINE �~ FOUNDATION __.._ _ AGRICULTURE WELL OTHER WELL PITS/SUMPS ...._..........._..__..._._...� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 13 Industrial L] Open Bottom El Manteca Dia. of Welt Excavation _ Dia. of Well Casing CJ Domestic/Private U, Gravel Pack 0 Tracy Type of Casing__...._ Specifications M Public 9 Other r, Delta Depth of Grout Seal �_ _ Type of Grout I I Irrigation _..........Approx. Depth 1 I Eastern Surface Seat Installed by Repair Work Done Ll Type of Pump _ H.P. ............__ State Work gone Well-Destruction CJ Well Diameter Sealing Material (top 50') Depth Filter Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAtR/ADDI-TION-1-i--,OESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence._.....� ComrrrerCial_ other Number of living units:_.A.-.._ Number qA bedrooms Character of soil to a depth of 3 feet: sxlywoWater table depth ' SEPTIC TANK C-Type/Mfg• eiP Tfi<+Ls _ Capacity P No. Co - � Compartments PKG. TREATMENT PLT.O " Method of Disposal r Distance to nearest: Weltf�_ Foundation _,Plop"Line r LEACHING LINE Lil No. 6 Length of fines , t t'�` .,Total tength/size FILTER BED 0 Distance to nearest: Well J'Z+�! Foundation.-.2–V t Property Lina rxv SEEPAGE PITS lb- Depth z2 r —size__.__• tai V ' Number SUMPS 111,4 Distance to nearest: Well �... f_ Foundation 100t Property Line 26 OtSPOSAL PONDS 1-2 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, W* rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I ceirtiiy that in the performance of the work for which this permit is issued, I shall not employ any person in such mann&r as to became subject to workman's compensiation laws iSf C ifisrtiira:"Carit'ratinaYs fining or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,I shelf employ persona subject to workman's compa.. tion laws of California." l The'applicant must Cali far r cited Inspections. Ct)mplslo drawing/an reverse sides�r Signed D(_ _ _ T1tIs: ✓ r+L+ A` Data: �t9 ♦ / R DEPARTMENT USE ONLY r w Application Accepted by Dewe uL-16 –37 Area it Grout Inspection by A bay k 7F nal Inspection by. C-t-+A Date " '- r5 3 7 Additional Comments. 7 f T? Stk '466.6781 O Lodi 369-3621 0 Manteca 823-7104 D Tracy 835-15A Applicant . Return all copies to: Environmsntal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009. Stk., CA 95201 a 11 tNFOFEE AMOUNT DUE• AMOUNT REMITTED jx 41 0 RECEIVED BY DATE P'ERMITNO. . EH 1}24 Wv.7,-,; 7a .•+`_ !/ J '1 J�-�Sl.. t3 /�" EH 14.28 ' v V