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-- ��7G1A'-t1,/.�Y , L-v u u J ;` APPLICATION FOR PERMIT ( : SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELi ON AVE., STOCKTON, CA l `Telephone {209) 466-6781 #� n d4-aJLtie 1"'`` ` `f� PERMIT E'XPIRE'S--1 YEAR FROM DATE ISSUED �Y (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. } C r� ' Job Address C Ci City A,, Lot Size PM Owner's Nar/. f c0er. _ "'Adi3Fasss �+1°+ / .. .- Phone' Contractor 61 n ` Address Licensee PhonZ �Sly' 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 g INTENDED USE "TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing !. :.- . _ ❑ Domestic/Private ❑ Gravel Pack��r ❑ Tracy Type of Casing �ry Specifications ❑ Public ❑ Other ❑ Delta Depth df'Grout"Seal r"'- Type of Grout 1 } ❑ Irrigation. ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump-_, H,P, FyS Done Well Destruction El Well Diameter Sealing Material (top 50')5 ' \ - ' Depth Filter Material (Below 501 ; TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION o septic system permitted if public sewer is a vailable within 200 feet.) Installation will serve: Residence_ Commercial_ Other ,'T_ Number of living units: r-- Number oof bedrooms Characte,of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg �^ � C p ity No. Compartments "t PKG. TREATMENT PLT. ❑ Method of Disposal tir ± i Distance to nearest: Well ( 7-Fo datiar Property Line LEACHING.LINE ❑ No. & Length oflines -- -�.- Total length/size i ^•� t FILTER BED i. ❑ Distance to nearest: Well Foundation I Property Line SEEPAGE PITS } Q Depth Size k t fL Number SUMPS ; ❑ Distance to nearest: Well Foundation--�? Property Line I DISPOSAL?ONDS ❑ i ! ■ 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 agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not 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 applicant ust call for all r ired inspections. Complete drawing on reverse side. Signed ► Title:: } Date': y OR DEPARTMENT USE ONLY r Application Acceptedy i Date �� + Area Pit or Grout Inspection Date Final Inspection by D� I Additional Comments: 7 ❑ Stk 466-6781 ❑ Lodi -36211 ❑ Manteca 823-VJ04 ❑ Tracy 835-8385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA.95201 FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT•NO. + EH 13-24(REV.5/a5) t` - EH 4428 ��^ ©C7 1d �' -" C�& I��.7