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APPLICATION"FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I 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 Cdunty 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 7��9 �i {/o'"{ City �7"�C.Y Lot Size �7AA`G1S PM Owner's Name -AV,,44f6t, Address 1 ( Phone Contractor.��/Y S4iY dMA ft-ve, C� w Address vP License No. '85��_Phone_ TYPE OF VV1 l L/PUMP; NEW WELL!❑ `��=� '_WEL•L�REPLACEMENT_RO + DESTRUCTIO7ND PUMP INSTALLATION ❑-- _ SYSTEM REPAIR_❑ ' _ OTHEDISTANCE;TO NEAREST: SEPTIC TANK SEINERLINES � ` DtSPOS L FL'D. t P. LINE FOUNDATION � AGRICULTURE WELL OTHER WE'L'L '�. /SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA^^-CONSTRUCTION SPECIFICATIONS + ~� I D Industrial ❑ Open Bottom ❑_Manteca Dia. of Wel! Excavation ❑ Domestic/Private ElGravel Pack Die:,of Well Casing 11 ❑>Tracy _^a,. .TYPe Df Casing' ''. f`l Public F'f7 Other Specifications Cl Delta Depth of Grout Seal f Type of Grouter _ I I Irrigation t _.-Approx. Depth. l 1 Eastern a Surface Seal installed by �- Repair Work Done T _ Pump -� H. ' State Work Done_ � �a '' Well Destruction El of ❑ Well Diameter Sealing Material {top 50'1 'y ._c ;' Depth zJ` k Filler Material (Below 50'l \ ,J TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR,ADDITION 01 DESTRUCTION ( I I septic system permitted if public sewer is �1 A.0 available within 200 feet./ Installation will serve: Residence L Commercial_ Other - -�; -ti Number of living units: --Z Number of bedrooms aCharacter of soil to a depth of 3 feet: `CA4 _AO r 1 SEPTIC TANK ❑ Type/Mfg-,,4Water table depth Capacity No. Compartments PKG. TREATMENT PLT. ❑ F _ . r Method of Disposal 1 t Distance'to nearest: Well r _Foundation + i •Property-•Line.` 1 LEACHING LINE0 No. & Length of lines / SQA FILTER BED i —�O Total length/size ❑ Distance to nearest:. Well �� r • f � Foundation �+� Property Line Y SEEPAGE PITS 11� Depth Size SUMPS ` — Number Ll Distance to nearest: Well Foundation / DISPOSAL PONDS L., 4 Property Line J 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 + y rules and regulations of the San Joaquin Local Health Di'ktrict- "- Nome 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 u employ any person g such manner as to.be' 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 all required inspections. Complete drawing on reverse side. Signed Xa.ai�' Title: �1 � Date: ' 4f— t FOR(DEPARTMENT USE ONLY Application Accepted by Date Pit or Grout Inspection by Data Final Inspection by e_� 0 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 . O 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 t FEE a INFO AMOUNT DUE Y AMOUNT REMITTEb c- RECEIVED 8Y DATE 7 PERMIT No. ♦ EH 13-24 HIEV.I/k 5) (/��-�� f EH 14-26 7,F ! � U C/ �/ �� q0 !�