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F f APPLICATION FOR PERMIT S.• ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA o, Telephone (209) 466-67811 — PERMIT EXPIRES 1-YEAR FROM DATE ISSUED �L (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 No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance Local Health District, s l f S7k� Lot Size PM ' Job Address � � O �• �� City Owner's Name 7 fa AS A LAuJ,��t/� Address 1477, �.A4��7E ,LA1r Tea9�� Phone _ r Contractor FLair� �� Address �� Af7�LB 'ems � License No.9�y 71716 Phone ---q7' TYPE OF WELL/PUMP: 'NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ PUMP INSTALLATION•❑'- SYSTEM-REPAIR-❑ 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 (71Industrial ❑ Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy „_-,__;type of.Casing Specifications Q i f-1 Public ❑ Other C1 Delta Depth of Grout Seal r Type of Grout—.— I rout I i Irrigation —.-Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter y Sealing Material Itop 501 Depth Filler Material IBelow 50'I TYPE OF SEPTIC WORK: NEW INIL-1/commercial TALLATION I 1 REPAIR/ADDITION l i DESTRUCTION !No septic system permitted if public sewer is available within 200 feet-1 Installation will serve: Residence _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet : Water tahie depth SEPTIC TANK ❑ Type Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. &I'Length of lines Total length/size FILTER BED LJ distance to nearest: Well _Epundation r Property Line SEEPAGE PITS l I Depth Size ' �' Number t SUMPS L] Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin counly ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict.. f 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, 1 shall not employ any person in such manner as to become subject to workman's compensation taws 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." ; II The applicant must call for all required inspections. Complete drawing_on reverse_side._-- .-,..:,:x.-..^_—_-.�...-.. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date rea 2 Pit or Grout Inspection by Date Final Inspection by Date 2 � Additional Comments: ❑ 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 i FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO ��/�/Jy} +.EH13-24(REV.1/n5) is, 11�jo / �V 6/" ' EH 14-28