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APPLICATION FOR PERMIT nC9 �1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA J� Z Telephone (209) 466-6781` S� 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 Ryles and Regulations of the San Joaquin Local Health District. /�� A _/ A W Job Address S W/ avNe.- AZALEA V /VA6t City, 9"Po" Lot Sire �3 PM Owner's Name J6hN V0AJJGt2, Address �IPBN cc,I /�II Phone Contractor S4.y 4-at-0 q /'�A s� 1'•Q. License No.Z1 LZZO phone ` - 36 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 1:1El »M� PUMP INSTALLATION SYSTEM REPAIR OTH ❑ tom• DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,,^^ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing vV ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation __ Approx. Depth ❑ Eastern Surface Seal Installed by z� Repair Work Done ❑ Type of Pump H.P. State Work Done �J Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 `Z TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is QJ available within 200 feet.) A3 Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal N Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line Q9 SEEPAGE PITS ❑ Depth Size Number �V1' SUMPS ❑ 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:"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 applica call r all re ire inspections. Complete drawing on reverse side. Signed X Title: EsT'�/'�'7NO D Ile— Date: ` mFOR DEPARTMENT USE ONLY Application Accepted by \I CJS.(n Date $�- Area Pit or Grout InspectionbyDate Final Ins coon by Date Additional Comments: ! /2-Yf w�- i t� ii^ L, *-y- �.Gy.... n./- ��/'rtr ZJ �cef�• ��li.n -t�(f d- )'v�uo liK4((< ❑ Stk 4666781 Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835-6385 Applicant-jieturn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. B x 2009, Stk., CA 95201 �v Kerro✓� VUR(-� aG,v-t fu' !-eve • VVla6(� � a �yLa( IFEENFO AMOUNT DUE AMOUNT REMITTED C SH �/�'RR�EECEIVED BY DATE PE114 T''NO. aEH I}29 P!w.i/esr '�J ��) I Q101? Y"�/ S-10—� 77f EH WW