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APPLICATION FOR PERMIT r,. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �j Job Address Z3 � d K 9 �o e c. A_� 4 City' Lot Size 1-20 PM Owner's Name t/G`ire-- ?Yl G1.t/ NJAA r� Address 2-56 6 0 W` A1" A Phone Contractor LEi Address _7 4-7LLicense troZg':23Phone 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS p� ❑'Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ilia. of Well Casing C-1 DomesiiclPrivate ❑ Gravel Pack s ❑ Tracy Type of Casing Specifications= t M Public ❑ Other _H= -Delta Depth of Grout Seal Type of Grout I I Irrigation " .____ Approx. Depth t I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material stop 50'► Depth Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION t l REPAIRlADDITION l I DESTRUCTION l 1 INo septic system permitted if public sewer is l available within 200 feet.) Installation will serve: Residence_ Commercial_____ Other ' Number of living units: I _ Number of bedrooms '2— Character of soil to a depth of 3 feet: Water table depth 1,20 SEPTIC TANK W Type/Mfg C nL!ae." Capacity /9?00 04 No. Compartments '2— PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Sa Foundation 9 Property Line 5 ' LEACHING LINE 1f No. & Length of linesf 30� �- Bio Total length/size 79 r Z FILTER BED ❑ Distance to nearest: ' Well k Foundation 101 Property Line $ c SEEPAGE PITS [*- Depth Size 53 4.1 e Y Number SUMPS L7 Distance to nearest: Well /dD Foundation /0 Property Line S ! DISPOSAL PONDS ❑ r s" _ e S 1 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 followings l certify that in the performance of the work for which this permit is issued, 1 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 must call for all�required inspections. Complete drawing on reverse side. Signed X r Title: 44=elm Date: 2`2-6--f 7 FOR DEPARTMENT USE ONLY Q / A plication Accepted byArea it r Grout Inspection by 41V Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 0 Lodi 369-3621 0 Manteca 823-7104 0 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 +AMOUNT DUE /AMOUNT REMITTED 11 CASH KRECEIVED BY DATE r PERMIT'NO. a EH 13-24iREV.iiH51 �0 �. • 7_[ -f(`l� ^7„r��i4� EH t4-2t3 a �. �Vj'�~ �G.Cl6 / / i