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3 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 (Complete in Triplicate)'- Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereindescribed.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. Job Address Se i y..yam_ / City Lot Size aPM Owner's Name ��l��S 7",�,rttl ,2_ Address _ S.Ass1 c=– Phone a _. . ^4 Contractor AZM Address /�®S' e✓, 1-1 LL A.✓ - , ---�— License No.�Y�'a�76 Phone TYPE OF WELL/PUMP: NEW WELL ❑ : WELL REPLACEMENT ❑ DESTRUCTION ❑ s f i� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE T0,NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION ' AGRICULTURE WELL OTHER WELL PITS/SUMPS 7 INTENDEDIUSE TYPE OF WELL PROBLEM AREA. CONSTRUCTION-SPECIFICATIONS ❑ Industrial ❑ Open Bottom '❑ Manteca Dia. of Well Excavation Dia. of Well Casing, �= r ❑ Domestic/Private El Gravel Pack v; El Tracy' i Type of Casing ` - ' Specifications F 1 ❑ Public ❑.Other ❑.Delta Depth of Grout Seale* - Type of Grout r ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed y`' Repair Work Done ❑ Type of Pump H.P. State Work Done V. Well Destruction ❑ Well DiameterIL i Sealing'Material (top 501 DepthFiller Material (Below 50') F 1, = r mayI TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑`,av,(No septic system permitted rf public sewer'is'--" p / ,. ailable within 200 feet.) Installation will serve: Residence v Commercial_ Other -= -- I! Number of living units: Number of bedrooms Character of soil to a depth f 3 feet: I–A// Water table depth � �' ')� SEPTIC TANK,+ Type/Mfg �� J, ®9LL CapacityJ2i00 No. Compartments Z PKG. TREATMENT PLT. ❑ __Method of Disposal Distance to nearest: Well�A Foundation_ /D Property Line .est LEACHING LINE { �o. & Length of lines _ !1 Total length/size Z,46, X -A- FILTER FILTER BED i! ❑ Distance to nearest: Well A//a Foundation4L Property Line -- �� I _ SEEPAGE PITS:, EDepth �S Size " - + Number '~•r` I . �c�� t � SUMPS iii❑ Distance to nearest: Well Foundation J57Property,!--ine tem DISPOSAL PONDS I ❑ 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 ori 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 inpsuch 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 Californial:� The applicant must call for all required inspections Complete drawing on reverse side. Signed x - Title: Date: _' �FOREPART NT USE ONLY ` A lication Ac le ted b r PP P Y '�v �' Date Area Pit or Grout Inspection by Dated Final Inspection by Date fl , Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ? EliTracy 8356 385 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,�Stk.; CA 95201 FEE INFO AMOUNT DUE. AMOUNT REMITTED CASH RECEIVED BY. DATE PERMIT"NO. 3 ._ .+ EH 13-24(REV.1/s 5) �9 ., EH 14.26 ` �:� 1� Ca - , 1 p�