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E APPLICATION FOR PERMIT 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 g QALSA2 City S 77,�-A-1 Lot Size PM Owner's Name `-PPA -6-f- (�/�I /L L(J!/Gib�Address .S'.4iYl� Phone Contractor ":X 7. W 0-0 Z Address 7 Al, AD License No.e#.7_'%---76 Phone Y4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ElDESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDE151TSE---TYPE OF-WEtI:""^--PROBLEM AREA----CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public F1 Other ❑ Delta 11 Depth of Grout Seat Type of Grout I I Irrigation ---Approx. Depth f I Eastern Surface Seal Installed by Repair Work Done ❑._--Type of Pump., H.P. ". State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') s Depth Filler Material (Below 501 e\ TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION ilQ DESTRUCTION I I (No septic system permitted if public sewer is `((-�� -- available within 200 feet.) r`or Installation will serve:"Residence_*_X Commercial_ Other Number of living units: Number of bedrooms Character of sod to a depth of 3 feet: i, Water table depth SEPTIC TANK ❑ Type/Mfg _� _s,��+A aft- Capacity L' No. Compartments PKG. TREATMENT PLT. El _ -_ Method of Disposal k Distance to n6are§r Well Foundation Property Line i ° IS Total len th/size LEACHING LINE ,- ` ❑ No., of fines �� 9 . FILTER BED ❑ Distance to nearest:_Well: Foundation Property Line SEEPAGE PITS, I Depth aZJ �- Size- f �1g Number o SUMPS e "``L]—Disterice`to nearest: Well AJIA_ Foundation. 14 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. j 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Z1114 Date: 002 SF�0ARTMENT USE ONLY R Application Accepted by Date ^� Area Pit or Grout Inspection by Dat li ZAV�Final Inspection by Date__ 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, Stk., CA 95201 FEE UNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO '1) CASH ///► /�y�/� +.EH 13-24(REV.t/H 5) V `90. �� /_// -/7 '~,,/l EH 14.28 t lll.., f"�F'"