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i E . APPLICATION FOR PERMIT { SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 1} 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 A AA&i5 1&11e5_ City Lot Size PMr r , r 4 Owner's Name �- L1��fi �f C k Address Phone Contractors Name 5lf D 4 &W&D_ License No. `*"��3''7� ' Phone d-r' 71 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ # PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE f 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l } El Public 1-1Other C1 Delta Depth of Grout Seal f Type of Grout V 1 ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair W6rk Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') J # Depth Filler Material (Below 501 f TYPE OF'SEPTIC WORK: NEW iNSTALLATION C] REPAIR/ADDITION DESTRUCTION El (No septic system permitted if public sewer is .� h---___ - -- I -_ available within 200 feet.) f 9 Installation will serve: Residence'/ Commercial_ Other Number of living units:--I— Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK ❑ Type/Mfg r (1 r 77AA(rCapacity # No. Compartments ` PKG. TREATMENT PLT. ❑ Method of Disposal Ir[ Distance to nea rest:;._,._,Well Foundation ' Property;Lin@ - LEACHING LINE ❑ 'No. & Length of lines oe ig Total length/size 1 FILTER BED ❑ Distance to nearest:" e I u' Foundation 'Property Line i SEEPAGE PITSDepth $'S Size ' .� " Number f{ SUMPS I ❑ Distance to nearest; Well Foundatiod _ SCJ __ Property Line_ r DISPOSAL PONDS ❑ &14 �E E 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 I rules and regulations of the San Joaquin-Local-Health District. f ^ M I Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the woik for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensatiori laws of California."Contractors 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." ! r $ ' The applicant must call for all required inspections. Complete drawing on reverse side. Signed �Til I- = Date: a �r..F.OR 0E1Pg 'USE ONLY v 1 f i Ar �` , 3- Application Accepted by Date woA Pit or Gropt Inspection by Date' Final lnspectiod by "" Date Additional'Comments: ' + ❑ Stk 466-6781._.,_.,.._.❑:Lodi-369-3521._.::_,E)_Manteca-823-7,104,,.i—-[:.,Tracy-835.6385 .r{ Applicant'Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ti FEE- AMpUNT DtJE " —AMOUNT'REMITTE[)' RECEIVED"BY","" DATE PERMIT"NO. INFO CASH , + EH 13.24{REV.16183- a •� O J!7�[.I Li—I � EH 1426