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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL"HEALTH DISTRICT 1601 E. HAHLTON AVE.,.STOCKTON, CA Telephone 42091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate} "`` ''� y'.� L: }�' •lYi- .K 3' lm [.�'S 'fl .' it. 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 Ryles and Regulations of the San Joaquin Local Health District. 4" 34 tr ,, :•,,,, r;:L Job Address 0 151W/R W4/V =' City. A t.4 Lot Size 'lj tie, Owner's Name Ail`!/rR/1� f��Af Address y GI14/1/5o N Phone Y Contractor_ AVN Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS O INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ' Ll Other ❑ Delta Depth of Grout Seal Type of Grout A [IIrrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done ) Well Destruction ❑ Well Diameter- Sealing Material (top 50'} Depth - 1 Filler Material iBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence f Commercial_ Other r E . Number of living units:Z Numbe1,r of bedrooms AIL — { Character of soil to a depth of 3 feet: 4-dAd1z Water table depth Ar, SEPTIC TANK .T a/Mf 0 Y1/ ��e. iC YP g Capacity�a'�.E}O:3 14, No. Compartments PKG. TREATMENT PLT. ❑ .• L.`> Method of Disposal 1 .Distance to nearest: Well-Ze/ Fouridation Property Line ZZQ. � f LEACHING LINE Z No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well_jai' Foundation 61$� Property Line O SEEPAGE PITS O Depth I Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line ;- DISPOSAL PONDS ❑ ly- i 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 F 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." Contractors hiring or sub-contracting signature certifies the following:"I certify that in th 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 Title: WAle- Date: _`Z/a�� 8�� 4 FOR DEPARTMENT USE ONLY Application Accepted'by Data ` 2 Area Pit or Grout Inspection by Date Final Inspectioh by-_( �3G.w�Pn• ate d1--a-na..•.i. Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all-copies to: Environmental ea th Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE. •�. AMOUNT REMITTED C RECEIVED BY DATE PERMIT"NO. i + EH-13-24{REV.1/s 51 —ls4 p p EH 14-26 '-1 / q,� S •..s�7