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1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I'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 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 J j�� p City f Lot Size/ PM Owner's Name%._Jy Address AP/ A90)( tt.J Z;26 __ Phone /t Contractor IZWAOT/1/s/hrN. Address (Q& �)Il�(a�r -License NoAaW1G O Phone -3ZJ0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION (91 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ; FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ rte.. INTENDED USE TYPE OF VV41L, PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial ❑ Openj'Botr� -£ ❑ Manteca Dia. of Well Excavation Dia. of Well Casing fflDornestic/ ❑ Gray�e�l,Pack� ",ry l Tracy Type of Casing Specifications 1`1 Public M Othe'F C S [�.�pfelta Depth of Grout Seal Type of Grout I I Irrigation _..ApprOK:�Dep 1,0,6Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump � s ] _ '"'��-p�-_ .y�� State Work Donei I Well Destruction ❑ Well Diameter s,', Scaling Materia p,50, ' UAP) Depth Filler Material (Below 50') 4 TYPE OF SEPTIC WORK: NEW INSTALLATION 111 REPAIR/ADDITION I I DESTRUCTION !*,(No septic system permitted if public sewer is aTzailable withinA6 feet.) Installation will serve: Residence_ Commercial_ Other � Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: -t�.-T tl� Water tableNd pth SEPTIC TANK ❑ Type/Mfg _ � � Capacity— o. Compartments PKG. TREATMENT PLT. ❑ fr r Me hod of Disposal I Distance to nearest: Well Foundation Property L3, j �' LEACHING LINE ❑ No. & Length of lines Total length/size k [ FILTER HED ❑ Distance to nearest: Well Foundation Property Line {�I SEEPAGE PITS 11 Depth Size _ Number a '� SUMPS ❑ Distance to nearest: WellFoundation [Property, Line r DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that—the—work will be done in acc Jdance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Dr'ktrict. # ! f Home Owner OT 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 lawsCalifornia." Contractors Miring or sub-contracting signature certifies the following: "I certify that in the performance of the work for whickrthis permit is issued I shall em to ers_ns subject to rkman's compensa- tion laws of rfo ia." _ The applic t mus call or c-tions Complete drawing r v se side. Signed X Title: 1' - , Z�Date: FOR DEPARTMENT USE ONLY G T Applic ion Accepted by C/1 D to .-. 6r Area p Pit or Grout Inspection by Date Final Inspection by 1 Date ' 2�^ b I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 FEE3 ' INFO AMOUNT DUE AMOUNT REMITTED MASH RECEIVED BY DATE PERMIT NO. + EH 1321(REV.r/n5) EH 11-28