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�APPLICATI'OWFOR PERMIT .- SAN JOAQUIN LOCAL HEALTH DISTRICT ENVIRONMENTAL HEALTH 1601 E. HAZELTO:N$AVE„ STOCKTON, CA PERWTISERVICES Telephone t.(209(466-6781 "' �-, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heteby 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. 18&2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. l � '- y p Job Address /=3 / f��DD F / !� City_A0AW1 Ae Lot Size ef-40iffX PM Owner's Name //,�54 AJ ",e.,?.4 Address S Phone Contractor AAe,02> Address 7 Al A-Zr License No. 's-�� _Phone 4L-V-.39 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ FdS'nl PUMP�INSTALLATION El SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST;SEPTIC TANKSEWER LINES, DISPOSAL FLD.1 t PROP. LINE FOUNDATION . " �a AGRICULTURE WELL . OTHER WELL ~PITS/SUMPS r INTENDED USE TYPE OF WEILLf PROBLEM AREA CONSTRUCTION SPECIFICATIONS T❑ Industrial Ll Open Bottom ❑ Manteca Dia. of Well Excavation , Dia-of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type-of-Casing _ Specifications (7 Public ❑ Other ❑ Delta Depth of Grout Seal �r Type of Grout.—_I ] Irrigation —."Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done O Type of Pump H.P.,". .� �f State Work Done Well Destruction ❑ Well Diameter ,/Sealing Material (top 50') Depth •' -Filler.Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I l �flEPAIR/A! J/ u' DDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) ercia F / I Installation w,ll'serve: Residence / Comml? Other r - Number of living nitsC':'=� Number of bedrooms Character of soil to a depth of 3 feet: 6"_4 LWater table depth SEPTIC TANK y ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ / !f / Method of Disposal Distance to nearest: Well f Foundation Property Line t � _ LEACHING LINE ( No. & Length of lines f-/DO Total Ilength/size DOz ;FILTER BED ❑ Distance to nearest: Well Foundation 540 .' Property Line SEEPAGE PITS IP( Depth a S I Size ' `H Number SUMPS- LSI-..Distance to'nearest: _'all Jib Foundation '� '7S Property Line '7.f s DISPOSAL_P_ONDS C7�y-�.•- �- ! 1 hereby certify that hhave 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 iin'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 :" 1 ,FY ., The applicant must call for all required inspections. Complete drawing on reverse side. Signed X _t Title: Date: F R DEPARTMENT USE ONLY (� J Application Accepted by. 1?1F Date S ��/ Area / 1!_V_ Additional or Grout Inspection by Da e 6 Final Inspection by--r4I , dCiYJ 0ate! o D Additional Comments: r ❑ Stk 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 �ry "fFal�- FEE P (NEO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT NO. + EW.13-241REV.tier) S-_Z g�107„2. EH 14-ZB