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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t (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 713 6 96 �] l7 U _ City Lot- Lot Size PM Owner's Name Aveyi K Address 36�6, B6P7 /zG/_ Phone ,ems --A � �t Contiacto��-/}/ jest `r aY-address-4w�� L� v -009 itle — License No. l�y "�/—Phone 3 ' •� -- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy .r Type of Casing V Specifications f'1 Public ❑ Other n Delta Depth of Grout Seal---• Type of Grout 11 Irrigation , __.Approx. Depth II Eastern Surface Seal Installed by Repair Work Done :'L —Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter_ Sealing Material (top 501 Depth Filler Material (Below 60'Iy �" x -- TYPE OF SEPTIC WORK: NEW INSTALLATION]"] REPAIR/,ADDITION ' DESTRUCTION I 1 INo septic system permitted if public sewer is _ f -- ` '.�...-------.._,.-.._-.- available within 200 feet.l IN •°.rte � ,.....�-�-�..-.__,.._._:..--� -_ Installation•w�serve: �Re is dC ence, Commercial_ Other - Number of living units Number of bedrooms Character op oil to�a,depth of 3 feet: ��'� P ¢ •.,V+Jaterttabfe depth SEPTIC TANK ."F' 0 Type/Mfg A-ts CifT Capacity�Gy4 V No'Compartments ?` PKG. TREATMENT PLT. 17 Method of Disposal t Distance to nearest: Well -40" Foundation O Property Line' pr LEACHING LINE [ No. & Length-of lines; _. l d0 Total length/size /040" FILTER BED; Distance to nearest: "Well Foundation 407" Property Line yf F SEEPAGE PITS 11 Depth Size Number SUMPS 1 ,y Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hareby'certify that:l,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 isignature 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 became 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." — T The applicant mu call for all required inspections. Complete drawing on reverse side. Signed X .� . ...� 4Ta F ,.,T• �e1 L ti n Data: 3` F ARTMENT USE ONLY 11 Application Accepted by Data, Area G� Pit or Grout Inspection by Date Final Inspection b ate�O ol Additional Comments: Old t"'�-ow— ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ anteca 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 I FEE INFO AMOUNT DUE AMOUNT REMITTED CH RECEIVED BY DATE PERMIT'NO. ♦ EH13.24(REV.tin51 �If. !30 t EH 14-26 �"j