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APPLICATION FOR PERMIT F SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA r Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED c (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. 1 1 i Job Address 3 5(a E. S r9 i9 T�, rxy�.�1 City (Y1 c3 rn C o Lot Size 35Si X .SSD PM Owner's Name Dv. 1Ro1AA0AV wlk ;0,r%%.5 Address /06 NYA'e" _ka.Ae_ Phone Contractor's Name CQSe+k License No. M Phone Ib a TYPE OF WELL/PUMP: NEW WELL ❑ WELL 13EPLACEMENT ❑ DESTRUCTION ❑ PUMP iNSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL_D. --PROP.-LWE- _ —.FOUNDAT40N-t--AGRICULTURE-WELL OTHER WELL PITS/SUMPS € INTENDEDUSETYPE 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 i ❑ Delta Depth of Grout Seal Type of Grout 1 ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by J Repair Work Done ❑ Type of Pump H.P;y State Work Done w i ) Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 0 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is avaikable=within-200=feet-) -- - - � Installation will serve: TP Residence—. Commercial— Other Number of living units: I Number of bedrooms Character of soil to a depth of 3 feet: Water table depth �� V SEPTIC TANK 2/ Type/Mfg n evcLiga P� Vmy% tfCapacity No. Compartments c2 d PKG. TREATMENT PLT. ❑ J Method of Disposal Distanceto nearest: Well 1-70 Foundation A 01 Property Line I LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well !'7�' Foundation .201 Property Line 4D . I SEEPAGE PITS ❑ Depth ( Size Number SUMPS ❑ Distance to nearest: Well Foundation _PropettyrLine_ "^ ' ��„DISPOSAL_PONDS-�.❑�--Yx �...��..� �-k- �--"...--Qom.-:�:.r�. �,:r.�---�-_ -- --- - - 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 Zfall wired inspections. Complete drawing on r verse side. Signed Title: Date: 1—;5 8 7 FOR DEPARTMENT USE ONLY Application Accepted Date rI-�o�� - Area Pit or Grout Inspection by Data Final Inspection by Date F Additional Comments: ❑ Stk 466 6781 El Lodi 369-3821' 'i'�Ulanteca 823-7104 ❑ Tracy 835-6385 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO �AMOUNT DUE . AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. j + EH 14-261REV.101831 �