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�X, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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 descri This appkation 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 � � y 4 , S.� City A-tc AJ Lot Size PM Y` Owner's Name Address f©J 3 d A �_/I_ ---5 Pone ?v`o g- ' Contractor_ a .s Address �(J Y J I` _License,Nd � o -rPh X\ ! TYPE OF WELL/PUMP: NEW WELL _7 WELL REPLACEMENT ❑ DESTRUCTION ❑ of PUMP INSTALIATtON C SYSTEM REPAIR ❑ OTHER ❑ GGW DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE 4 f FOUNDATION _____AGRICULTURE WELL _ OTHER WELL_ _ PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA'-`CO'N_STRUCTION SPECIFICATIONS U t D Industrial ❑ Open Bottom Manteca Dia:of Well Excavation Dia. of Well Casing t L7 Domestic/Private ❑ Grave) Pack ❑ Tracy Type of Casing_-. Specifications i 4 Public O Other ❑ Delta Depth of Grout Seat Type of Grout t f V Lt Irrigation --Approx. Depth ❑ Eastern 5/Surface Seal Installed by t � Repair Work Done ❑ Type of Pump, H-P. f State Work Done t Well Destruction C Well Diametet _ Sealing Material{top 50'1 Depth_. Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION C REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is - `" available within 200 feet.) r Installation will serve: Residence�._ Commercial_ }Other_ - _+ i Number of living units: Nu tier of bedrooms__.—_ �� f r 5 Charactei of soil to a depth of 3 feet: : ; - Water table depth- t SEPTIC TANK ❑ Type/Mfg _. ; n`^• _. _ Capacity ; No. Compartments 4 PKG. TREATMENT LT. ❑ r jMethod of Disposal a 1 Distance to nearest: Well Foundation _ Property.Line { i � � f p^•j r'-' � i LEACHING-LINE $ No. & Length of lines - G - Jif Totall�rFgth7size I4 ^-' LTER BED 2 Distance to nearest: Well Foundation ( _ Property Line ____ f SEEPAGE PITS �epth Size 3 ��. .! Number, SUMPS i Distance to nearest: Well �/ /�.j;;Foundation �Property Lane y 0 y t DISPOSALrPONDS Irhereby certify than I have prepared this application and that the worW'witl be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Sark Joaquin Local-Health.District. Dome owner or-licensed agent's signature;certfles the topgwicertify that in the performance of the wody,afor which this permit is'-issued, I shall not employ any person in such manner as to become'subj41 0o torkman's compensation laws of Cafifornia." orltractoPs hiring or sub-contracting signature certifres the(following: "I certify;that in the performance bf tfie work for which this permit is issued,1 shal empfoy persons subject to workman's compensa- tiqn laws off California." 1 }r r; j .` -, z� +• T�1e appli ust call for all re%ireddnisp4ctions. Complete drawing on reverse side. I X - �-•3 - -rtle: - .CPUC . ._..-.-^... Signed 1tt t� -) .. FOR DEPARTMEIVT�USE Of1�Y Application Accepted by ' 3 �' -� Date _2l`v f Area Prt r Grout Inspection by Data Final Inspection bye / at Additional Comments: .\012— 4 Stk 46"781 Lod, 369-3621 G Ma ca7323-7104 ❑ Tracy Ato(cant- Return ail copies to: Environmental Health Permit ervices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520? FEE AMOUNT DUE AMOUNT REMITTED CASH H RECEIVED BY DATE PERMIT''NO. EH 1321[REV.i%s e1N- EH 1428