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f APPLICATION FOR PERMIT SAN JOAQUIN,LOCAL HEALTH DISTRICT 16011. HAZE T ON AVE.; STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,!1'%p , (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. .fob Address /M. A A.0g City 04AMWO2 Lot Size 3,9 i4C&C PM Owner's Name B&O J&neJ 2Q C�94S Address -S,400,6 — Phone Contractor A"'Lci 5gn,,yS Address _ License No..&N Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D industrial ❑ Open Bottom ❑ Manteca Dia.of Well Excavation Dia.of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications D Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth C Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50'? Depth Filler Material (Below 501 - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONX DESTRUCTION ❑ lNo septic system permitted if public sewer is i t available within 200 feet.) Installation will serve: ResidenceCommercial _ Other ✓ Number of living units; limber of bedrooms 1 V 1 Character of soil to a depth of 3 feet: ,�40Be I Water table depth / f SEPTIC TANK D Type/Mfg r,_rr_ Capacity_ 12400 No. Compartments 9 PKG. TREATMENT PLT, D I Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. &Length of lines /�tJ�'SX,Cs� Total length/size /� 2 FILTER BED Distance to nearest: Well 4�t Foundation 40 Property Line — SEE?AGE PITS ❑ Depth Size_ Number e SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS D 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 f 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 permit is issued, I shall not t 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 appl' mus II for re ired inspections. Complete drawing on rev side. .1 C Signed Title: /A 1 Date: FOR DEPARTMENT USE ONLY Application ACcept by _ Date el.-y,$'96ea CE3 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: �f/t( 1 � Qu � ' 2- 7 Stk 466-6781 D Lodi 3693621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 I r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH [ 4 EH 1324.REV.1/e 5; EM 14-28 I