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j{ APPOCATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 9 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. 1862 for weitlpump and the Rules and Regulations of the San Joaquin Local Health District. , Job Address1—�.1-Ic .t�.. City_ Y '�.__ Lot Size — PM Yi Owr er's Name ., o. t2L� 12 ii!r4'.ttr7"�S _ Address �` Phone. �7s"/✓"�y L7lr Address b't?V.x r L t!'C iV.4- A""`% License No.�� J� / Phone�.2.1—k '1 jJ �✓ �ontrarlor_. �!Tll u' j_ _. TYPE OF WELL/PUMP: NEW WELL Cr WELL REPLACEMENT i.:_1 DESTRUCTION Chi -- ---- .—__......_...... ' -,� lump INSTALLATION -1 ? SYSTEM REPAIR :I OTHER [ DISTANCE TO NEAREST:(SEPTIC TANK SEWER LINES .- _.._..,..�-.Dl$POSAL Ft D.________ PROP. LINE.-- FO'JNDATI(7hl ": �...__.....__ AGRICULTURE W£LL _._ 'OTHER+lWf M PITS/SL9MPS# .....— INTENDED USE 11TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C l Irtdustriai FT Open Bottom Cl Manteca Dia.of Woll Excavation _ Dia. of Well Casing r� LI Domer;ticlPrivate• Cl Gravel Pack U Tracy Type of Casing... Specifications t f"I Public 1_1 Other 1 Delta Depth of Grout Seal Type of Grout-.L _ ...... D_ I I Initiation Approx. Depth I i Eastern Surface Seal Installed by _. Repair Work Done Ta of Pum State Work Done ,,yp p �. Well Destruction 1 1 Weli Diameter Sealing Material Stop 501 n Depth Filler Material (Below 50'i TYPE OF SEPTIC WORK: NEW iNSTAt.LATiON REPAIR/ADDITION I I DESTRUCTION I I (No septic system permuted if public sewer is t availabte,within 200 feet.) Installation will serve: Residence_ Commercial ....._ 4.- Other " ,�` Ae 5004 t Number of living units: 7 Number of bedrooms.._-._-.--- 1 Character of soil to a depth of 3 tees; . � rY a'�^t __. Water.table depth SEPTIC TANK (£, Type/Mfg _p�" _ , ' .._.._._,_. .. ...___ Capacity 1'oZd t ' _ No Compartments '� I PKG. TREATMENT PLT. 1.I t Methtid•of Disposal Distance to nearest: Well Foundation_. .___ Prupeny Liri, LEACHING LINE l21 No. & Length of lines _ �� _- Total length/size tOer`. FILTER BED Z!, Distance to nearest: Well }1 Foundation._ Property Line � r SEEPAGE PITS I 1• Depth Size __._ Number SUMPS L' Distance to nearest: Well -1 Foundation Property Line _ DISPOSAL PONDS 0 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 "r s. 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 issuer), i shall not ampi.oy any person in such manner as to become subject to workman's compensation taws of California."Contractor's hiring or sub-confracting signature cartifies 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 compan7.a- tion laws of California•" The applicant m1rcall for all required inspections. Complain drawing on reve(lp side. A rr Signed X - -_. _..._........_._ Title:. \` ��Jtu` �li-�.1._. Date, DEPAW MEINT USE ONLY Application Accepted by CL_ -__. Data Pit cir Grout Inspection by Date Final inspection by — Datyr✓i✓yG Additional Comments: Ll Sik 466-6781 L' Lodi 369.3521 ❑ Manteca 823-7103 111 Tracy 835.6385 _ Applicant- Return all copies to: Environmental Health Permit/Swvices 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95301 FEE INFO AMOUNT DUE AMOUNT REMITTED - CASH RECEIVED BY DATE PERMIT NO, H v CH 14 201 1;24 6 V E ' ]3