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1 i7 APPLICATION FOR PERMIT + SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA r 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 describ d. This application is 1 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 ,M ! t • City *G�L Lot Size %is PM t CD Z.�000 A 1Pwa�t awl 1?wl��s Owner's Name G Address SQA_�+-+eG R Ca- 9 z.(410 ^ Phone �� J Contractor ��t~i. the L rl�t AddressTO �. ' 4sL qg / 6 S a License No.3-10 f TYPE OF WELL/PUMP: --•��_Phon�_ y 7 / W WELL �(��( �04�WEL�LACEMENT LI DESTRUCTION ❑, PUMPJNSTALLAT(ON p SY EM REPAIR ❑ OTHER. 2 l ! '2� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1 J DISPOSAL FLD' PROP. LINE (� F UNDATION AGRICULTURE WELL OTHER WELL—.— PITS/SUMPS INTENDED USE 0 YPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIQN5 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation� Dia. of Well Casing ❑ Domestic/Private Gravel Pack Tracy Type of Casing PVA i`) Public Specifications Ll pe C7 bther ❑ Delta Depth of Grout Seal -E Ir �anor��k Approx. Depth I I Eastern — T Pe of Grout 'Surface Seal Installed by a epair Work Donn❑ Type of Pump N H.P. State Work Done _ ., ell Destruction ❑ Well Di�teto— Sealing Material (top 50.) DepthFiller Material (Below 50') A r YPE OF TIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTR UCTiON I I Wo septic system permitted it public sewer is available:lwithin 200 feet.) Installation will serve. sidencei _ Commercial— Other i G Number of living units: ber of bedrooms 4 Character of soil to a depth of 3 feet: rWater table depth C w EPTIC TANK ❑ TypelMfg Capacity F ~ KG. TREATMENT PLT. L1Ne,'Compartments V Method of Disposal Distance to nearest: Well � 3 ZO Foundation Property Line 04EACHiNG LINE Ll No. & Length of lines - � �/� - -- Total length/size i' C COILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size 4" SUMPS — Number Cl Distance to nearest: Well Foundation Property DISPOSAL PONDS Cl 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. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work:,for which this per is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the followin "l 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 lifor The applica mus all for all r i inspecti plat yawing on reverse side. Signed rs _ Title: Dater FOR DEPARTMENT USE ONLY f Application Accepted by 1� �. Date �D'l Area T ! 4 .- Pit or Grout Inspection b t y - rr Date lL .� Final Inspection by_. �f-�P�C.t Date /� 3� �O U'ditional Comment (,rltUQ� iv L , O Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1123-7104P Cl Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave:, P.O. Box 2009, St k., CA 95201 FEE AM Oi1NT DUE AMOUNT REMITTED INFO RECEIVED BY DATE ��PESMITNO.,E1113.24iREV.tix511 ry ` _ ICr4 1r^^ C l tir�ems1 —7