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_ APPLICATION FOR PERMIT 2 ,\ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I 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 made in compliance with Sam 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, L KA Job Address - O S'S'.3 iV u 5 h � 1�� City 0_scd* Loi" Lot Size /Z PM j Phone ��3 - 330 9 I Owner�'s,Name ✓e7' Address ! &OP,z_ Lt> � ANL4� License No.yyy_AW1 Phone y Contractor A/vT/�Gn' _ 'd 501!AddFess s� ( TYPE OF WELL/PUMP: NEW WELL ❑ WELL. REPLACEMENT ❑ DESTRUCTION ❑ f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I �, " DISTANCE TO NEAREST: SEPTIC AI`&,'�� ' t 'SEWER LINES DISPOSAL FLD. PROP. LINE -T 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 ❑ Glave-Pacd ❑-Tfacy eType of Casing Specifications 1 Public fl Other ❑ Delta # Depth of Grout Seal Type of Grout I I Irrigation -Approx. Depth I I Eastern Surface Seal Installed by - i Repair Work Done _ ❑ Type of Pump H.P. State Work Done Well_Destruction El Well Diameter Sealing Material (top 50}4 Depth Filler[tllaterial (Below 50'1 -- ` i NEW INSTALLATION I a REPAIR/ADDITION L I DESTRUCTION ! I (No septic system permitted if public sewer is TYPE OF SEPTIC WORK: i { available within 200 feet.) Installation will serve: Residence_/ Commercial_ Other y� Number of living units: '� Number of bedrooms i, _ �A Character of soil to a depth of 3 feet: -�.^4wd �o�M Water table depth 4. V t SEPTIC TANK 1Z Type/Mfg A-& L'//ST Capacity f X00 No. Compartments 4 `'PKG. TREATMENT PLT. 0 -' z Yom` rT Method of Disposal Distance to nearest: Well ---Foundation S� Property Line.... r °LEACHING LINE 11' No. & Length of lines ; `� Total length/size S ? r .'FILTER SED ❑ Distance to nearest: Well {a y0 �� Foundation &d Property Line fD ivSEEPAGE PITS r I I Depth Size�' Y X �� — Number • t SUMPS IX Distance to nearest: Well Foundation Property Line 7O 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, and rules and regulations of the San Joaquin Local Health District. # i ) Home owner or licensed agent's signature certifies the following;F'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"-COi)ff 6f65 hiring oh- r sucontracting signature certifies the following: "I certify that in the performance of the wo k for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." 4 The applicant mu t_catllcir:all required inspectidhin.,Complete drdwing on reverse side. Signed X� Title: Pate: i l F I_QEEA.#TMENT USE ONLY P - Application Accepted by} , Date Area -" 1 Pit or Grout Inspection by M_ Date Final Inspection by Date) t Additional Comments: Z ❑ 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 AMOUNT REMITTED z, RECE=VED BY 1 BATE- PERMIT'NO. INFO EH 13 EV.1/K51l/�75 EH 14-26