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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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 San Joaquin County Ordinance No.549 for sewage or No. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. /Svo Job Address -5-11-k Al. SANGE.t/T City LV 1 Lot Size A�`+e�S 7{' PM Owner's Name R AIEY XA 174LE4 K .+ Address -Y'-4 Phone v Contractor F6 p �A-- • W4901) Address (vda A)- 1-1-I-L-►AAJ License No.t y- Z6 Phone -f 3 7,1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i 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 ❑ Public ❑ Other Delta Depth of Grout Seal Type of Grout ❑ irrigation -L—Approx. Depth `0 Eastern Surface Seal Installed by Repair Work Done El Type of Pump H.P, State Work Done ` Well Destruction_ ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: s NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) fInstallation will serve':, Residence' _ Commercial_e/other � Number of living units: "` Number of bedrooms 306 ti Character of soil to-a depfh of 3 feet: 5A NDy L 0`p'nf ----------]Nater table depth / d4 uv SEPTIC TANK l�3' Type/Mfg Capacity�4 An s No. Compartments z— PKG. TREATMENT PLT. LJ 4. Method of Disposal Distance twnearest:- Well §0 .-Foundation- '10 Property Line M12 LEACHING LINE QK No. & Length of lines -!5�:ZOO Total length/size -Z,/ { FILTER BED ❑ Distance to nearest: Well 1 20, Foundation ""e, Property Line g"Q...f SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 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 all required inspections. Complete drawing on reverse side. Signed X .1.�-r� Title: Date: 701 EPART11,i1ENT USE ONLYApplication Accepted bDate `D 6 Area L Pit or Grout Inspection y Date Final Inspection by Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354f%' 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 CK RECEIVED BY DATE PERMIT N0. INFO CASH + Ek 13-241REv.1/651 EH 1428 --i