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,l APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA �! Telephone (209) 466-6781 , PERMIT EXPIRES:1 YEAR FROM DATE ISSUED r (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 of the San Joaquin Local Health District. Job Address /3 t So-°,'� ,Az 5 . L �-a -*ity Lot Size' PM Owner's Name ��l 25� CjA,foW,5V^L,,;l Address o2 6 �151' TzAvAJi W Phone Contractor , Address 0:0 -31"5'a� ir W- wv'"" License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 13 SYSTEM REPAIR ❑ OTHER ❑ h DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 - FOUNDATION AGRICULTURE WELL . OTHER WELL PITS/SUMPS INTENDED USE`—, TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial El"Open Bottom +- ❑ Manteca i Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack • 1-1.Tracy Type of Casino Specifications d ❑ Public j; Other ❑ Delta 4 Depth of Grout Seal ;_ Type of Grout i 'O Irrigation. _ Approk. Depth ❑ Eastern Surface Seal Installed by l r Repair Work Done [IType of Pump H.P. State Work Done Welt Destruction ❑ Well Diameter Sealing,Material'{top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION_ - REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 4, ; �. t available within 200 feet.) Installation will serve: Residence J- Commercial'—* r Other, `a { � Number of living units: Number of bedroomsL? d 0, Character of soil to a depth of 3 feet: ', A P6 734-7. Water table depth /� SEPTIC TANK Type/Mfg =_,tet[' c� L, y� ' E opacity../K" No. Compartments PKG. TREATMENT PLT. ❑ if 1 Method of.Disposa Wp Distance to nearest: Well s Foundation 6 Property Line e'FD LEACHING LINE No. & longth of lines �„��' � l`` Total length/size _ FILTER BED XE, sl Distance t`nearest: Well Foundation Property Line ' SEEPAGE PITS Depth !T OCT Size �3 Iµ Number SUMPS 0111 Distance to nearest: Well Foundation %tom?T7 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, and rules and regulations of the San Joaquin Local Health District. i Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not r{ employ any person in such manner as to become subject to workman'spompensation 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." f The applicant must call for alk required inspections. Complete drawing on reverse side. 1 Signed X Title: 6�� ii Date: FOR DEPAR MENT USE-ONLYI:,. - Application Accepted byRI Date, Area } Pit Grout Inspection by - ate a1' _. Final Inspection by Date I Additional Comments: j ❑ 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 951201 f FEE q � INFO AMOUNT DUES AMOUNT REMITTED CASH RECEIVED By DATE PERMIT NO. - w.ww,�...—.ter-.r.-ar.. .+er,.+.• _ �..wr`--�-•/r�..,w,.•�..,..,�.-...-�.vsie...,a!wz�.u-ww.e...-«--r--............,..,�-..':. --_. �jy--I.-r-+^.-s -ne,wa.^•Nr� + EH 13-24{REV.1/8 51 EH 14-28 3 ' l6.=• h F+ I