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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E, HAZE T ON AVE., STOCKTON, CA Telephone 12091 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 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. 'Job Address 7 4o.YP tree City FTC*9 G OtV Lot Size- DA i'r PM fl .Owner's Name LTV P, Go ;9'e I APhone Address 6 ,Contractor 49", A&rhoeyv y S-ew Address 6002 tvcr 00410 l 9 oLicense No.�1P��/.,_.�I �Phone_ ;TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0 SYSTEM REPAIR Ll OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK , SEWER LINES ,DISPOSAL,FLD. PROP. LINE i FOUNDATION AGRICULTURE WEL[,: ' 0THER WELL PITS/SUMPS _ INTENDED'-USE TYPE OF WELL PROBLEM AREA r CONSTRUCTION SPECIFICATIONS' i❑ Industrial - ❑ Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing r~ .❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ."Type of Casing Specifications F Public -T—FI-Other Ll Delta Depth of Grout Sea! Type of Grout _ i I I Irrigation _ -•- Approx.;Depth 11 Eastern Surface Seal Installed by - * .Repair Work Done L7"r Type of Pump H.P. State Work Done _ f Well Destruction ❑ �Well Diameter —Sealing Waterial atop 50'1 Depth � Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW 1NSTALLATIONy1 REPAIR/ADDITION 13 DESTRUCTION I 1 INo septic system permitted if public sewer 'IS available within 200 feet.i �1 Installation will-serve:- Residence-"'I"""'Ci�Fr-rfme—rcial`= Other f 5 i . Number of living units: Number of bedrooms 6 y. t Character of soil to•a depth of 3 feet, k p Water table depth' SEPTIC TANK Ld 'Type/Mfg G `Capacity�-y�_ No. Compartments .� .PKG. TREATMENT PLT. ❑ Method of Disposal^ Distance to nearest.". Well 20 0 Foundation !o Property Line LEACHING LINE LCI. No. & Length of_fines_ 3 9�z._ Total length/size z FILTER BED ❑ Distance toynearest: Well Foundation Property Line 'off r SEEPAGE PITS 11 Depth Size-,V' .4 ./ ' X l Number _T I?r_Dis`tance to' - Well / ' �- _ Fouridati'n �e ' Property line _DISPOSAL�PQNDS ❑ ` 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 regulatioris.of the San Joaquin Local Health District. a ' Home owner or licansed,a ents signature certifies the following:g 9 g: "I certify that in the performance of the work for which this permit is issued, I shall not I 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." i The applicant mu t call for all require _d inspections. Complete drawing on reverse side. F , Signed X Title: v } Date: \ OR . ARTMENT USE ONLY ;Application Accepted by Date re Pit / Pit or Grout Inspection by Date' Final Inspection by spate Additional Comments: J 0 Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 . ❑ Tracy 835-6385 rApplicant - Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i INFO AMOUNT DUE I AMOUNT REMITTED CK F1 RECEIVED BY DATE PERMIT'IVO. a Eli 13-24IrtEv.'i/n51 _ ` -!,.. . ,.. t�' b t7 c �.�. ,=-gg {� f+17f j EH 14-26