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• ; .� APPLICATION FOR PERMIT $1'1 SAN JOAQUIN LOCAL HEALTH DISTRICT �}.� f 1601 E. HAZEL T ON AVE., STOCKTONd, CA t f / Telephone (209) 466-6781 '1 PERMIT EXPIRES 1'YEAR FROM DATE .ISSUED ( (Complete in Triplicate) i i 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. Jobi Address ]` �5, City Lot Size 7 PM Owner's Name A AM � r�� .T7�'� Address O� � G//71E/lr� rQ t°Q� Phone X3 — Z 2— Contractor YD5 Addressv� -1Ct Q ense No.'2900 Phone vy"J —//,?s TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL I'llD.-AZY PROP. LINE FOUNDATION. _ AGRICULTURE WELL- OTHER WELL- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 41-1 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private Gravel Pack )<Tracy Type of Casing U pecifications 11 Public El Other Cl Delta Depth of Grout Seal �T/ype of Grout I I Irrigation --.-Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump H.P. State Work Done Well Destruction ❑ Weil Diameter Sealing Material (top 50') Q , Depth Filler Material (Below 50') ` TYPE OF SEPTIC WORK: NEW INSTALLATION €1 REPAIR/ADDITION iJ DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other `dumber of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depthma: .,i i �y SEPTIC TANK ❑ Type/Mfg Capacity No. CompartinerltIv, E;f:a M PKG. TREATMENT PLT. ❑ Method of;Dl,posal ' i ` Distance to nearest: Well Foundation Property tine _ LEACHING LINE ❑ No. & Length of lines Total length/size V.,VT FILTER BED ❑ Distance to nearest: Well Foundation Property Line _ / Y .I�'v1f1i�C.], i N,NTC,,i.,'T:A` ;, I eC1 .il Jl:4!L. 'J SEEPAGE PITS I 1 Depth Size Number f Y= ---SUMPS- .--4 _L1_-Distance to nearest: ., —Well ..Foundation.-- ----- - PropertyvLine - 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, an rules and regulations of the San Joaquin Local Health Diltrict. 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, 1 shall employ persons subject to workman's com' pensa- tion laws of Cal'ornia." The appli ant ust call for all requ' d inspection Complete drawinp evlrse si . Signed X -S Title: Date: .3 R D T ENT USE ONLY C� f Application Accepted by •r ^ 41 � r Date ✓ I Area Pit r Grout In ction by. ~�= Final Inspection by Date Additional Comments: Zaa ❑ Stk 466-6781 ❑ Lodi 369 1 ❑ Manteca 8&7104 _ ❑ Tracy 835A& Applica t- Return copies to; Environment y 11h Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT'NO. ♦.EH 13-24 R - 3- I EV.1/B 5) ` ^� EH 14-28