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a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT : ` A 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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. ,eD Job Address _ City 577--A Lot Size AMaA333 PM Owner's Name Q In a <"""''Ad'dress � E � -moi. Phone -3 7 l Contractor.- < dna I-00V-D Address._7 Al. Ae'7�LB .eT AXdl License No. Yf3-7G •..*Phone -9.37 TYPE OF WELL/PUMP: NEW WELL ❑ _ _ WELL REPLACEMENT ❑ DESTRUCTION D O PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER D 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 t Dia. of Well Casing ❑ Domestic/Private D Gravel Pack, ❑ Tracy Type of Casing ;' Specifications 171 Public F] Other - 17-1 Delta Depth of Grout Seal Type of Grout _ ! 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 !top 501 ; Depth Filler Material (Below 501 # i TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITIO DESTRUCTION l 1 (No septic system permitted if public sewer is }ti ,ei f 2hJ+ by 01,14, / a -Of k-el'i4a e available within 200 feet.) �vrr 157- -V I/ installation will serve: Residence_ Commercial II; Other °°_I — Jk-j j t/� Number of living units: —I— Number of bedrooms 2-- Character /Character of soil to a depth of 3 feet: I-Ax Water to le depth SEPTIC TANK W_ Type/Mfg Capacity No. Compartments w. PKG. TREATMENT PLT. ❑ .' Method of Disposal _ 5 Distance to nearest: Well 901 Foundation 20 �: Property Line y LEACHING LINE LieNo- & Length of lines BCJ r Total length/size 1490 -eA 2- FILTER FILTER BED ❑ Distance to nearest: Well- slPV_�2 � Foundation--A.Z49 r Property Line !019 SEEPAGE PITS I Depth Size_._._,!(2 � — Number . SUMPS ❑ Distance to nearest: Well Foundation_JZO Property Line IAO DISPOSAL PONDS ` ,❑ I hereby certify that I have"prepared this`application and that the work will be done in accordancewith-San_Joaquin-county ordinances, state-laws, and rules and regulations of the.San'Joaquin-Local Health District. Home owner or licensed agent's signaiure 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." Contracto'r's hrring 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 far all required-i nspections. Complete drawing on reverse side. -- s �/ Signed X t Title: _(' �. Date: -Y`-`� rJ2 f,s FOR DEPARTMENT USE ONLYIi. ' Application-Accepted-by 4Date Z�s U Area Pit or Grout Inspection Date Final Inspection by 9�_.0 rslJle- _ Date Additional Comments: 54 CZ '! +2o,�r� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 'Tracy 5=6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 o INFO AMOUNT RUE AMOUNT'REMIT7ED • 'CASH RECEIVED BY DATE PERMIT'NO. / r EH 1324!REV.I/x 51 78 it' Tl�CIyO�-- EH 11- ��« -