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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL 10014 DISTRICT 1601 E. HAlELTON AVE., STOCKTON. CA PERMIT NO. Telephone (209) 466-6781 (p �y DATE ISSUED PERMIT EXPIRES 1 NEAR FROM DATE ISSUED • (Complete in Triplicate) plication is hereby nude to the San Joaquin Local Health District for a permit to construct and/or install the work herein scribed. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or NO. 1862 for well/Pump d the Rules and Regulations of the San Joaquin Local Health District. D Address j'�`, A/r ;1/t:`i�1�A� Y!• Subdivlslon Name �, , �J y. / Phont LJ mcr's Name _�[ �C_Xw Ad e$S r� — r yy$S r7 Phone __ { mtractor's Name K>9oc%MA lr ��l eh so No. _ / ��- I ; k 'PC OF WELL/PUMP WORK: NEW WE WELL REPLACEMENT DESTRUCTION�) .�. i } PUMP iNSTALLA OTHER U SYSTEM REPAIR �] ; ROP. LINE iSTANCL TO NEAREST: SEPTIC TANK _p Q SEWER LiNES O15POSAc FED. D FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS ' ri INTENDED USE Tr?F OF WELL PROBLEM AREA 'LU%M 'RUCTiON SPECIFICATIONS ,e ; ] Industrial Open Bottom Manteca Dia. of Well Excavation ] Domestic/Private Gravel Peck G Tracy Dia. of Well Casing ]Public [1 Other (]Delta Type of Casing _[Q_e�/3 Irrigation Approx. []Eastern Specifications 3 ]Cathodic Protection Depth Depth of Grout Stal f'f ]Geophysical Type of Grout '� 1 v ]Other Surface Seal installed by TRK sf apair Work Done [] Type of Pump 51 _b HIP.H,P. U State Work Done all Destruction Well Diameter Sealing Material (top 50') —— — Depth _ Filler Material (Below 501 i ic sewer TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION ❑ (No septic tank or seepage Pit ava/ableewithinubl200 feet.) is r I g installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms lot site _ Water table depth Character of soil to a depth of 3 feet: No, Compartments SEPTIC TANK U Type/Mfg Capacity — Capacity Method of Disposal PKG. TREATMENT PLT. [J Type/Mfg Foundation Property line -- U SEWAGE SYSTEM � Distance to nearest: Well - DESTRUCTION — No. 6 Length of lines Total lenqth/site __— ---- LEACH-NG LILAC J 9 x Ll Distance to nearest: Well Foundation property Line FILTER BCJ - Size Number SEEPAGE PITS U Depth SIRiPS U Distance to nearest: Well Fnundation 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 District. Hone owner or licensed agent's signature Certifies the following: "i Certify that in the perfornunc• Of the work for which this Permit 11 issued, 1 shall not employ any person in such manner as to become subject to wOrkrcdnS compensation law•. of Crk forn hie Contractor's hiring or sub-Contracting signature Certifies the following: "I certify that in the perf OrmanCe Of the work for which this permit fs issued, 1 shall employ persons subject to workman's compensation laws of California." i The applicant must cy111 for all required inspections• Complete rawing/on reverse side, n C r(fete Title: Signed X - -- p�{1 ARTMENT USE ONLY Stec 466-6781 Application Accepted Dy �� r Area Lodi 369-3621 (] +� Additional Comments: --- --- Manteca 823-7104 y j Pit or Grout Inspection b Date L J —� r-' Datt - (:/ Trnry 835-6385 Final inspection by ��-y- ---- -►L— ar- nn A�R'�. P. lin, 2009, S0., CA 95201 Applicant - Return all Copies' to: Environmental Health Permit/Servlvs 1501 E. irl----- - -- - AMOUNT REMITTED - _- p[FFIV10 BY DATE PEDM.II N0.— FEE BASE AMOUNT DUEi� t-�-^--- - 10/H2 500 En 13•C4 NCV. 101Ni2 1446