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, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. Job Address /4 9.L,(, 7"UX_/a Y eez_lJNy AD City J ad> Lot Size ��XL�p PM Owner's Name A G,LE Ill M, [,-A LL Address s;'d /YJE Phone Contractor FLC?y?7 �•. jc9m�D Address Avg License No. Y 7Y7b 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 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 [7 Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout --- I 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 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence ✓ Commercial T Other Number of living units: / Number of bedrooms 3 Character of soil to a depth of 3 feet: - 6 I-Ay Water table depth SEPTIC TANK ❑ Type/Mfg /�_4� - �9�L Capacity (6061 No. Compartments - PKG. TREATMENT PLT. ❑ Method of Disposal `_ Distance to nearest: Well 1 ?ri 0 Foundation !O T Property-Line- SO LEACHING.LINE LST No. & Length of lines 3 - 40 r Total length/size 12-0 � FILTER BED ❑ Distance to nearest: Well 1 ODS Foundation 2-a Property Line �x SEEPAGE PITS i Depth 23 ' Size ,. _G _ Number SUMPS LI Distance to nearest: Well 1 DC7 Foundation—r�c7 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 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 no employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of sub-contracting signatura 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 applicantmust call for/all required`inspections. Complete drawing on reverse side. Signed X ,�T.l1�-..,/Y� l.(�� _. Title: Date: 2-�Z -9� QEPARTMENT USE ONLY t Application Accepted by L SL khims Date Area 1 i or Grout inspection by Date V G Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ 1 odK 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMO T REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. +.EH13-24{REV.)/A 5) EH 14.28