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�U APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 r, PERMIT EXPIRES 1 YEAR 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �t Job Address Os�, a=942+ A-4 City Lot Size Z�! X PM Owner's Name Address �S aA$E44 •Phone License No.Contracto t C Address 6 fZc- o Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL ]ARUCTION El PUMP INSTALLATION El REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ eco Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications M Public 17 Other Fl Delta Depth of Grout Seal Type of Grout I 1 Irrigation ___. rox. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ pe of Pump H,P. State Work Done_ * Well Destruction Well Diameter Sealing Material (top 50') "4r Depth Filler Material (Below 50') __ V TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is v available within 200 feet.) Installation will serve: Residence / Commercial Other Number of living units: __L_ Number of bedrooms A4- Character of soil to a depth of 3 feet: Water table depth 9 SEPTIC TANK 14'-Type/Mfg Capacity h" No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal \) Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines 6e) W!= Total length/size 2 QQ FILTER BED ❑ Distance to nearest: Well Foundation L✓, J-, Property Line SEEPAGE PITS I4,r'Depth Z$ - Size2"� Number �^ SUMPS 1 1 Distance to nearest: Well Foundation_�it- Property Line_S k �� DISPOSAL PONDS ❑ 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 District. 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." The applicaust call for all uire inspections. Complete drawing on reverse side. q Signed X V Title: __ AAI, Date: �Z ~j 7_4 FOR DEPARTMENT USE ONLY Application Accepted by Date / 2-.411 y `S Area Or Grout Inspection by a:�!-� - Date inal Inspection bW" Q' c- Date n'z Additional Comments: .1) t &k r IQe ,l�P� / ce �„2��f� -E,c,.�/ fs ny�Z+ �r El Stk 466-6781 El 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 95201CK 44 FEE /lf INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH13.24(REV.1in5) 76- 00 I • f Z—'U_QG113 EH 14-2e ( r'�a