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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 �J PERMIT EXPIRES TYEAR FROM DATE ISSUED I (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, f the San Joaquin Local Health District. I Job Address 3 2 l V Ave- City Lot /Size r� /aG�2es PM Owner's Name SID 14l:4..T/A Abl ECrAl Address it{,, phone �2 Al�2 S�s� - II. 21093 Contractor WA / W Address Q W/LC OX &D License No.VZi:EEJ G Phone 0 TYPE OF WELL/PUMP: i NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ f- PUMP INSTALLATION ❑ , SYSTEM REPAIR ❑ OTHER Q{�dc"I� �Ur!`, C - DISTANCE TO NEAREST: SEPTIC TANK• SEWER LINES DISPOSAL FLD. _ _PROP. LINE 4 FOUNDATION AGRICULTURE WELL I OTHER WELL . PITS/SUMPS!) INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing ' ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i'I Public t:) Other Cl Delta Depth of Grout Seal Type of Grout Irrigationh. —.-Approx. Depth i"I Eastern Surface Seal Installed by ,I1 Repair Work Done ❑ Type of Pump H.P. t State Work Done Well Destruction ❑ Well Di`�ameter Sealing Material (top 50') Depth 1P Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I:t REPAIR/ADDITION i I DESTRUCTION l I INo septic system permitted if public sewer is I�I f available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: :Number of bedrooms h Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg. Capacity No. Compartments( I� PKG. TREATMENT PLT. ❑ Method of Disposal IN f Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No-Y& { �& Length of lines � r Total length/size 1M FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITSI ] Depth Size _ Number SUMPS I. Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Dli§trict. t + Home oner 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 employ any person in such manna'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 c tl f r aft r I ired inspections. mplate drawing on reverse side. I r Signed X Title: 0 � �7 ,P � } Date: II' FOR DEPARTMENT USE ONLY Application Accepted by,' Date ! Area Pit or Grout Inspection by ' II' Date Final Inspection by Date J Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3&21 ' C Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: EAvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE f .4..�.. INFO AMOUNTIPUE AMOUNT REMITTED CASH RECEIVE(]8Y DATE PERMIT'NO, f.EH 13-24(REV. I� c \\ :M' EH 14-26 S o .F V� S I) .c U z5�{� 7�� 9111-/�/�S? I a IPIIIW .6