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r APPLICATION,FOR PERMIT "A SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ' Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . ; t(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,weli/pump and the Rules and Regulations of the San Joaquin Local Health District. " Job Address 117%Z City S77<AJ Lot Size �3.7X PM Owner's Name RAKVAAID AANZ-L Address^ 5.�9r1�' t + Phone f Contractor /=�D yD �J� - Address lad x—p, L G-L14AI License No.i� 2'7L Phone�r:C-3 Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION j AGRICULTURE WELL ____L 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 1-1 Gravel Pack LJ Tracy;, Specifications Type of Casings r P ❑ Public ❑ Other ❑ Delta '' Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top_50')`' ' Depth # Filler Material (Below 50') Vit^ TYPE OF SEPTIC WORK: NEW INSTALLATION. —REPAIR/ADDITION'-.1]—DESTRUCTION ❑ (No septic system permitted if public sewer is d available within 200 feet.) ! ECOID Installation will serve: Residence`/ Commercial_ Otherw �X 1.57 � OF } Number of living units: _.- �- Number of bedrooms 3 t f j (_ Water table.depth i Character of soil to a depth of 3 feet A SEPTIC TANK V� Type/Mfg' r�OtiI��_ L- Capacity 2 No. Compartments i -f r %1 f f Method of Disposal PKG. TREATMENT PLT. ❑ : t - 1 r � Distance to nearest: Well /DB Foundation Z4 Property Line 740 LEACHING LINE %No. & Length of lines .Z� g r _ Total length/size 74 x z FILTER BED ❑ 'Distance to nearest:' ell 1/00 f' Foundation_._ — Property Line SEEPAGE PITS -" Depth ^2��` _Size4= r� T Number 'h f SUMPS ❑;~'l Distance to nearest:. Well .-./_ 4 Foundation /60 Property Line 464 e DISPOSAL PONDS 0 fi. 1 1 \ hereby certify that I have Qrepared 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. I Home owner or licensed agent's signature certifies-the following: "I certify that in.t- he 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 lawns-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•worktnan's compensa- tion laws of California." The applicant must call f r all required inspection Completeidrawing•bin reverse side. yTitl &; - Date: FOR DEPARTMENT USE914LY- k Application Accepted by t Date Z -L Area Pit or Grout Inspection,by Date Final Inspection`by Date k Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3&1 ❑ Manteca V3-7W5_', O'Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE ''AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT NO. INFO �._. t EH 1324(REV.1/R 5) EH 14-28 __