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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �O7 p-�' 4,5—GO-"�b 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 T'cl 7 2— PERMIT 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address Lf BC! .d A AZ 437 City Lot Size PM Owner's Name _,BAYAA) C AU6n&6!Z )Address 5'A»-z Phone Contractor F4—"P C_ Vl w� Address 7 N. Aa46--L-e60—r— License No. jq:. 1-7C. Phone}tet-3 97/ TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION_ ❑ SYSTEM REPAIR O OTHER-L]—. 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 F1 Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout 1 Irrigation Approx, Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Weil Destruction ❑ Well Diameter Sealing Material Stop 501 ' Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITIONX DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet-) Installation will serve: Residence� Commercial Other Number of living units: / Number of bedrooms Z Character of soil to a depth of 3 feet: L X Water table depth SEPTIC TANK ❑ Type/Mfg AEX1 S 7 G e Capaci#y No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Fqundation Property Line LEACHING LINE No. & Length of lines 4-- 40f Total length/size FILTER BED ❑ Distance to nearest: Well,/ 00 r Foundation 7.4 a Property Line G SEEPAGE PITS 1 Depth ��1 Size___._.- 3 y Number O �, « r SUMPS Ll Distance to nearest: Well 1 I , 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 Diltrict. 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 ail required inspections. Complete drawing on reverse side. Signed Xs Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pi or Grout Inspection by Date .� Final Inspection by Date Additional Comments: ❑ Silk 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, Stk., CA 95201 „#p FEE --JAMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT'NO. INFOCon . EH 13-24(REV.tiM5) L EH 1146 (�.rL,+ V ! T