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role APPLICATION FOR PERMIT SAN JOAQUIN.LOCAL HEALTH DISTRICT i 1601 E. HAZELTI ON AVE., STOCKTON, CA 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 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 43 A-2-A'S 4",(ems', City /57"225K.Q Lot Size SAG PM /1010 t�lE4fF Owner's Name ��Address /GG S 'D Phone �1 Contractor's Name License No. �SJ'��- Phone 3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ .,RUM P_INSTALaTION-❑ -REPAIR-0.,r —OTHER'❑ DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATIONS AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open BottaM ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack"' ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ' t❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. a State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 i LU Depth Filler Material (Below 50') ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONJK DESTRUCTION ❑ (No septic system permitted if public sewer is i available within 200 feet.) Installation will serve"`-Residen .�. t Number of living units: Number of bedrooms Character of soil to a de6th of 3 feet: Water table depth SEPTIC TANK VType/Mfg ��L. Capacity No. Compartments PKG. TREATMENT PLT. ❑ 3 ,0} _ 6,4 ; Method of Disposal Distance„to nearest: Well; - Foundation _ Property Line119114 A-7 LEACHING LINE ❑ No. & Length of lines 4 Total ngth/size FILTER BED iX Distance to nearest: Wel4<,?_y_" Foundation Property Line .r-y SEEPAGE PITS ❑.._Depth - - ---Size-- --- _-- Number SUMPS ❑ Distance-to ntteares't,:.�- - Well_^"_Eoundation Property Line , DISPOSAL PONDS ❑ 1 ! i -� -s" •' hereby certify that I have prepared this application-and-thai'thefwork will-be d6e_in qc�cordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health'District. ti Home owner or licensed agent's signature certlfies�the following:""I� e p ertify that in.tNerformance of the work for Which this permit is issued, I shall not employ any person in such rnanner'as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following:"Lcartify that.in_ the performance-of th work-for which,this permit is issued, I shall employ persons subject to workman's compensa- tiondaws of California." 'The applicant must call fo II re 'ed inspections: Completed wing on reverse side. Signed X�• d—Tl_1/�u/ 3 Title: / Date: J O FOR DEPARTMZNT3l1SE ONLY �f Application Accepted by Date r � -1Y Area ` Pit or Grout Inspection by Datea x'41 Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 1 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Aye., P.O. Bax 2009, Stk., CA 95201 t� r FEE 'k p. — — �•. mow.—�w.—�eaT`^��++—e�sr��_ .,..� ��+,y� INFO ,.-AMOUNT DUE., AMOUNT REMIT-TED CASH-_ . RECEIVED BY DATE PERMIT''NO. 11324 TREY.101931 J1 S, ESU — ��- g - �� i%28