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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 466-6781 w PERMIT EXPIRES 1'YEAR FROM DATE ISSUED 1 (Complete in Triplicate) f 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address "f d t✓ N -2,4111 S" P-D City 1.670� Lot Size �Ca XG pM k C Owner's Name A�fS�.�T. .lyA '_ln2D,Qress SrlE Phone Contractor OJ60D Address_7 AJ, License No. 7.!176 Phone 4195-397 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LJ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAR TIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE `k FOUNDAT AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE 'TYPE OF WELL ;ROB"E CONSTRUCTION SPECIFICATIONS ❑ Industrial ' - % „ ❑ Open Bottom ❑ Manteca Dia. 1 Excavation Dia."of Well Casing ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing _ Specifications 1-1 Public (_f Other C] Delta Depth of Grout Seal Type of-Grout. I I Irrigation �.-Apprpx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done x, Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 _ I TYPE OF SEPTIC WORK: NEW INSTALLATION V REPAIR/ADDITION 1 J DESTRUCTION l I INo septic system permitted if public sewer is . .. ., - available within 200 feet.) . f Installation will serve: Residence-el Commercial____ Other 4-197- 07=- �ECca/z!J •l Number of living units: -1— Number of bedrooms Pm10/ �7-29 /'F 71-Z- 11� Character of soil to a depth of 3 feet: S' +d/ C- - - Water..table depth SEPTIC TANK ❑ Type/Mfg C - q--L Capacity b6(a Na. Compartments O PKG. TREATMENT PLT. ❑ � Method of Disposal � Distance to nearest: Well I D Foundation d Property Line pi i( LEACHING LINE No. & Length of fines 3 - Total length/size FILTER BED ❑ Distance to nearest: Well 67 �7 . �-rte Foundation �� operty Line 7-r� � V j SEEPAGE PITS Depth Size �-r Num 3 --- SUMPS LL Distance t earest: Well rr Found ion �� Prope Line /� DISPOSAL PONDS El 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 bi1trict. j 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 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,1 shall employ persons subject to workman's compensa- tion laws of California." The-applicant must call for all required Inspections. Co ete drawing on reverse side. - Signed X - `Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 4 Araa Pit or Grout Inspection by Data Final Inspection b} I Dat Additional Comments: ❑ Stk 466-6781 ❑ 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 " AMIOUNT DUE AMOUNT REMITTED INFO C H- RECEIVED BY DATE PERMIT-NO. +.EH 1324(REV.1/a 5) EH 14.2e