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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON AIN, C Telephone (209) 466-6781 PERMIT EXPIRES I'YEAR FROM DATE ISSUED R 5 p19x0 (Complete in Triplicate) ENVIRONMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct an iREIRI de11drk$e}eil,�r'1 -Fiibed. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address LZ&E7 S- AC06E PD, City aCA�1�� Lot Size JWACRZS PM Owner's NameI)IAVL� �. 41,6$ Address=�"¢3 Q HZWS—A Phone sy3_2 Contractor rasa 3&V S. / cense No Phone - TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION Cl PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK O � SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL: - _- O-T-HER WELL'5V_�L_ FITS/SUMPS_/��;,,�} INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation l2 Dia. of Well Casing T_Dor estic/Private •Z�Gravel Pack ❑ Tracy Type of Casing cS e�Spe�ific�i�� of Feed�y % I"1 Public Cl Other Cl Delta Depth of Grout ea� T�Pero Grout I I Irrigation _�Wd.-Apprax. Depth >4-Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 �- f TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permittedif public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms- Character of soil to a depth of 3 feel: R" Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line tA r LEACHING LINE CI No. & Length of lines Total length/size �7 FILTER BED ❑ Distance to nearest: Well Foundation Property Line V - e i SEEPAGE PITS I ) Depth Size Number Sumps.,,,,,.. L1_ Distance to nearest: Well - - Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health District. I e 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, I shall employ persons subject to workman's compensa- tion laws of California." r The applic st f r all re u'ed inspections. Complete drawing on r se side �y �4 Signed X Title: Date: L/ F R DEP TMENT USE ONLY 1 Application Accepted by Date � el Area �0 Pit o Grou''Inspection by Date �� AWFinal Inspection In Date Additional Comments: 5 ❑ Stk 466-6781 ❑ Lodi 30-3621 ❑ Manteca 623-7104 ❑ racy 835-6385 Ap�p/lic t - rn all copi to vrrQ t nttal�I th Permit/Services 1601 E. Hazelton Ave Ave., P O. Box 2009„Sik. CA 9520 �.CadJz��.r< �c6rcy,c�4.m;b..s�lF�-y. .P��•Pe4f�F-�y/-S/fir �./��C/es+r F.•-� INFO EE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. +.EHi3-241REV.1/H51 Ol !_ EH 1428 1 l _�i