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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA- Telephone A_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 225 Saidi QyTckse Lam City Tr li Lot Size PM i Owner's Name AFM P 1CdJ: S 0111=7 Address P.O. 1213C 5811, S In Yl E& D Phone 415-571-2434 Contractor EkMlted1 Address 41674 Qhtjst= stxppt, i_icense No. 5%545 Phone TYPE OF WELL/PUMP: NEW WELL IN WELL REPLACEMENT ❑ DESTRUCTION ❑ Vq3or W7-11 X PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK >50 SEWER LINES >54 ft DISPOSAL_FLD. M PROP. LINE hA FOUNDATION >5 ft AGRICULTURE WELL OTHERWELL.__ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial - "❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1011Dia. of Well Casing 4" c ❑ Domestic/Private IN Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other ❑ Delta Depth of Grout Seal 81 '" Type of Groutll�� f I1 Irrigation -..-Approx. Depth „X Eastern Surface Seal Installed by d llPr _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction D Well Diameter 4" Sealing Material (top 501 4klo-y - VapCr FXtraCtiM Depth 251 Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Q A Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg _ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines Total length/size l 'FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS M L--1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Q 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 agent's signature certifies the following: "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. The applicant must call for all i�redA'RsRections. Complete drawing on reverse side. Signed X Title: P Date: S v R Eloise K. FOR DEPARTMENT USE ONLY " Application Accepted by Date Area Vwa��,, Pit or Grout Inspection by Date '� Final Inspection by A,4 L Date ! Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 .❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AqMOj/U%�NT DUE AMOUNT fREMITTED CASH 40 REC BY / DA/T�Ef PERMIT'ND. + EH WN(REV.r i k 51 V-3-�K/ Iql- 141