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` APPLICATION FOR PERMIT 43Le SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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. Job Address -2-31,2 ,��-,J��i��L��L�(-L L o Z) City dCV Lot Size PM S1�/VSe � Owner's Name _ _SAGL701V Address 9Q44ig: IMAV s MfAhone Contractifl:rT_�WA ess S icense NoZ��Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION�❑ -- SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.ffJ_QROP. LINE FOUNDATION —� AGRICULTURE WELL �� OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS sr ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation U Dia. of Well Casing j3-Domestic/Private Gravel Pack ❑ Tracy Type of Casing A/_ cSGr)'(-166 Specifications AIM jl� F1 Public n Other 010 ❑ Delta Depth of Grout Seal6~ 1 Type of Grout I I Irrigation Approx. Depth 'Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. Stateork lKone Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other a Number of living units: Number of bedrooms Character of soil to`a depth of 3 feet: II SEPTIC TANK ❑ Type/Mfg Capacityt PKG. TREATMENT PLT. El :::ftMethod of Dis 1 Distance to nearest: Well Foundation -0Npertty2198�0 LEACHING LINE Ll No. & Length of lines � 1j(Inlpf,{il FILTER BED ❑ Distance to nearest: Well Foundation PEfZjdf(j��rjEBb(� ES SEEPAGE PITS I I Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line 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:' ce ify 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 applica st f all req r inspections. Complete drawing on re e e sid .�- f Signed X Title: te: FOR DEPARTMENT USE VNL Application Accepted by Date /0 -74-0 �y 4-0 Area Pit or Grout Inspection by Date t - Final Inspection by Date 1 O� 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, Sik., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK V RECEIVED BY DATE PERMIT NO. + EH 13-241REV.iixs)