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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 �00 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �1 (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 4 R® �'�11G/1R City �77G"J Lot Size 10rAl7D_ PM ill; -44 9-2375/ Owner's Name F3.607 IZ- LA.ND Address 54,077Phone Contractor FLSL'D L • Looe Z) Address Z Al AI?,g AJ q 7` License No.6Z -7G_Phone} --.3''7! TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ f OTHER ❑'� '- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ,-PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA' CONSTRUCTION.-SPECIFICATIONS LJ Industrial ❑ Open Bottom. ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑��ravel Pack ❑"Tracy' u Type of Casing � Specifications (`l Public LI Other C7 Delta. Depth of.Grout Seal �� Type of Grout--- I rout _.I I lrrigation 'k-Approx. Depth I I Eastern `.Surface Seal Installed by _ Repair.Work Done ❑ Type of Pump H.P. A State Work Done_ Well Destruction LJWelf Diameter Sealing Material {top 5501 Depth Filler Material (Below 501 — INl -TYPE OF SEPTIC WORK: NEW INSTALLATION 1'1 REPAIR/ADDITION DESTRUCTION l I (No septic system permitted if public sewer is available within-200 feet.► Q• Installation will serve: Residence Commercial— Other Number of living units: __L Number of bedrooms .3 Character of soil to a deptAof 3 feet: 0_L,A5e_ Water table depth SEPTIC TANK C] �IType/Mfg AG-K 15 Capacity No. Compartments PKG. TREATMENT PLT. C1 ifl i Method of Disposal I'Distance to nearest: Well Foundation' Property Line � LEACHING LINE ❑ No. & Length of lines 6= t S -/A,& Total length/size FILTER BED r ❑ Distance to nearest.` Well Foundation Property Line \ I` I I , SEEPAGE PITS I t tDth _ Size ep __�-�_� ____ ~ Number SUMPS L71 Distance to nearest: Well61 es Foundation 10 Property Line Z-7 DISPOSAL PONDS ❑ .�. I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Sen Joaquin Local-Health-Distfict:---- Home owner or licensed agents signature certifies the following: •'l 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for akll required inspections. Complete drawing on reverse side. i Signed X � Title: La-Z. Date: i jS R DEPARTMENT USE ONLY Application Accepted by - R _ Dat l ^v Area l d Pit or Grout Inspection by .. .r Date Date Additional Comments: ✓1 ❑ Stk 466.6761 ❑ Lodi -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 9520V4f 1 I� + INFO A1�4]10UNT DUE AMOUNT REMITTED ed RECEIVED BY DATE t PERMIT N0. + EEH 13-24 H 1/-281FtEV.ti+s5) �! ~�E Im �d �{d �. J �� / L>f� I .II.