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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES TYEAR 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 ,S._ 20247A7rSAZ-1) City Lot Size AC-4455 PM Af,di-4AJ Owner's Name kA77E A. FEC*, z:2eefs7- Address �11A,x 2oJ076STJC�✓ 9�ICJ Phone Contractor D C, W&V7 AddreSS" f-Al- License No�7Y,?ff�7_4 -Phone 5L -C 337 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f7 Public M Other Cl Delta Depth of Grout Seal Type of Grout _ I I irrigation �-Approx. Depth I 1 Eastern Surface Seal Installed by 'Repair Work Done ❑ Type of Pump H.P. State Work Done Wel! Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION DESTRUCTION 11 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Z Commercial_ Other A Number of living units: —/— Number of bedrooms I — _ Character of soil to a de�pthh 3 feet: L_AA K—PSA 7' _ Water table depth SEPTIC TANK Type/Mfg d d —10V-4- Capacity-J Zai D No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i i • Distance to nearest: Well O Foundation Property Line LEACHING LINE ICr No. & Length of lines Total length/size 761 r ` FILTER HED ❑ Distance to nearest: Wel! Foundation 3 t4 Property Line SEEPAGE PITS l I Depth Siie Number SUMPS Ll Distance to nearest: Well Foundation Property Line 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. Home owner or licensed agent's signature certifies the following: "I certifythat in the performance of the work for which this permit is issued, I shalt 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 all required inspections. Complete drawing on reverse side, Signed X Title: Date: J��Z OR TMENT USE ONLY (� Application Accepted by Date L a-�— Area 0 Pit or Grout Inspection by Date Final Inspection by edwuj Date 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, Silk., CA 95201 FEE INFO MOUNT DUE OUNT REMITTED ASH RECEIVED By D TE PERMIT N0. rEH14-24IRE V.t/R5) - ©,�`}1! a -� �Iflq �1 1�e- t3H 14-28 C/