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APPLICATION FOR PERMIT O n SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 �1 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 M!V11 S• S/17.41c,4 2D City A1AA1. C-4 Lot Size PM Owner's Name Address SAS Phone Contractor _Ftgl,�_ ? ldo&PD Address7AAAD4ZS,:.e-r �— License No. 42sr7,76 __Phone &S'377/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION [71 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 1-1 Public ❑ Other n Delta Depth of Grout Seal Type of Grout _ I I Irrigation °_Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ' ] Well Diameter Sealing Material Itop 501 1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTAt_LATION D(" REPAlR-/ADDITION't t„DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Z Commercial_ Other Number of living units: Number of bedrooms 2. Character of soil to a depth of 3 feet: S AW n Water table depth SEPTIC TANK ❑ Type/Mfg Gd- Capacity 'L..a No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well to U Foundation 10 r Property Line f d LEACHING LINE E! No. & Length of lines -" 7 Total length/size /` + ' 2. FILTER BED ❑ Distance to.nearest: Well ! 7-D' Foundation a-0 ` Property Line SEEPAGE PITS [ l Depth __ Size Number I SUMPS ' Cl—Distance-to nearest: Well Foundation Property Line DISPOSA1 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.D utrict., " 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 i 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 applicantmustcall for ,all required inspections. Complete drawing onn�reverse side. I Signed X ,�f�fa+��Af L _4 Title: C x -_111 " _ ` Data: 3`3.7 FOR DEPARTMENT 6SE ONLY ' Application Accepted by /!%6 __ Data ^,;Z Z Area l -- -- z Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2049, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT NO. INFO r EH 14-2gIREV.t/N5i