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APPLICATION FOR PERMIT J SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. MAZELTON AVE., STOCKTON, CA � LA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . . A.), (Complete in.Triplicate) 1"d 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. S Job Address AOaLS �, S1A/BL.A 2 ST SIXAI ' _ / City Lot Size 7�x 3/.!< PM Owner's Name it ,�llE G�/ J b wELt_ Address SA-rK& phone 41,65LS Contractor�P"VD C, WBS D Address 40_r AJ, 44,LA4 4 Al ".0 License`No'14*rY'7 6 Phone bS-397 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ i OTHER ❑ DISTANCE TO NEAREST: SEPTlC,TANK SEWER LINES DISPOSAL FLD. PROP. LINE M FOUNDATION AGRICULTURE WELL OTHER WELL `: PITS/SUMPS INTENDED USE TYPE 6F WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ 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 ---Approx. Depth ❑ Eastern Surface Seal Installed by r !i Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ ,Well Diameter Sealing Material {top 501 .. Depth a Filler Material (Below 50'1 { TYPE OF SEPTIC WORK:" NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCT ( o septic system permitted if public sewer is I,//_ ailable within 200 feet.) Installation will serve: Residence IF' Commercial_ Other ? a Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK C1 Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation— Property Line sI SEEPAGE PITS ❑ Depth' ',—- Size•-•- Number SUMPS ❑ Distance to nearest: Well Foundation r Property Line DISPOSAL PONDS ❑ ,r I hereby certify that I have prepared this application and that the work will be done in accordance with'San'Joaq uin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ; - •+..n 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 Califom'ia."1,'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." i r The applicant must call f all required inspections. Co_ Iete drawing on reverse side. ? S { Signed X . � Title: � Date: � s D ARTM T USE ONLY 1 Application Accepted by r Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3621 ❑ Manteca 823-7104 ❑ Tracy 835-M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO _ArMOUNT DUE AMOUNT A.EMITTED f +':CASH' RECEIVED BY �J DATE PERMIT''NO. + EH 1324(REV.t/a5) y 5 V �,Y5,`P EH 142872