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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) F 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 a� 1 City-.s /11 _ Lot Size-Ay e6�'�_ PM Owner's Name L A Address -S Phone , Contractor RyXj> A, /fr��? —Address---7AI, 4AIX License ho.� Phone " TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ;f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ _--SEWER-LINES l DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL IOTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSi ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 7 Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation ---Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Donees C Well Destruction ❑ Well Diameter Sealing Material Itop 501 1�Q r Depth I .' Filler Material (Below 50') TYPE OF-SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.i Installation will serve: Residence�Commercial-- Other Number of livingunits: i y —+✓ Numbe�Lof bedrooms Character of soil to a dept of 3 feet Water table depth SEPTIC TANK Type/Mf klo -t' _ g Capacity Q No. Compartments PKG. TREATMENT PLT. ❑ 6J Method of Disposal Distance to,nearest: Well�� Foundation /-f Property Line Z61e LEACHING LINE No. & Length of lines Total length/size o "y 2- FILTER BED © Distance ton crest: Well_/30 Foundation ,30 r Property Line 1 30 r SEEPAGE PITS IDepth ——c Size rr Number SUMPS C Distance to nea� e t: Well Foundation ,/'7.0�. Property Line DISPOSAL PONDS _,-0 I hereby certify=fhat.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. 4 . f Home owner or:licensed agent's signature certifies-the followings"I certify that ihtt fe performance of the work for.which this permit is issued;I-shall not employ any parson in su"ch manner as to become- subject-to-workra n's compensation laws of California." Contractors hiringor sub-contractin <' certifies the following: "j'certify that in the performance of the work for which this permit is issued,'1 shall employ g signature i-tion laws of California." t. { P y persons subject to workman's coinpensa }tThe applicant must call for all required in 'ctions. Complete,drawing-on reverse-side. r Signed Title: — .. �Ay4 �• ,,+- •�:�. -- ----; # Dater ;jy' FOR DEPARTMENT USE ONLY � Y' Application.Accepted by ` bate Pit or Grout Inspection b pp Date Final Inspection by v Date Additional Comments: Ota 7?"/ p�7� ❑ 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 AMOUNT DUE Y AMOUNT REMITTED AMv INFO r f CK RECEIVED BY DATE PERMIT'NO. + EH 13-24 MEV. EH 14-26 ��