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n APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEiTON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES-1 YEAR"FROM DATE ISSUED (Complete in Triplicate) Application is hereby trade 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 -23040 AW1+'L-1 t3 � City ��' Lot Size l i�rre/a 67rYe PM Owner's Name Rd-i 4T.4,y e4fe 0Q4 V!r$'15*`Address-AD.%V �',C�.`mT f l�tl. `3 4 P 570 a Phone �"' Contractor AWT124WX 16 -29Address "4P `vt.' 1tff1 dlO&— License No.yYy 09l Phone." -V-I/j TYPE OF'WELL/PUMP: 'NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION '❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP_ LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Ll Open Bottom. ❑ Manteca Dia_ of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications. : FI Public L1 Other "n-Delta Depth"of Grout Seal Type of Grout >' 1 1 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 Malarial (Below 50'1 _ r <" TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION I #'tNo septic system permitted if public sewer is, available within 200 feet.) Installation will serve: Residence Commetcial._ Other r -Number df"living units: �� Number of.bedrooms Character of soil to a depth of 3 feet: Ado Get Sd' P Water table depth N.r SEPTIC TANK Z Type/Mfg pl"Nr Ce9S' Capacity/4,1116V No. Compartments A PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Ave' Foundation 30 r Property Line lil0' LEACHING LINE P No. & Length of lines �' yam' Total length/size li0 FILTER BED ❑ Distance to nearest: Well -zoo Foundation Y-4 * Ptoperty Line -'rO SEEPAGE PITS W Depth A ''" Size �L u PIA Number � SUMPS Ll Distance to nearest: Well AO Q Foundation Property Line !PD 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 Dftrict. 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;bed6me subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature' certifies the-fdllowind:"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 all for all required.inspections. Complete drawing on reverse side. Signed X Title: Date: O"'T 1 C/O FOR"D ARTMENT USE ONLY "... Application Accepted by Date ` Area Pi 'or"Grout'Inspection'by An6I Inspection'by ate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0.Manteca 823-7104 0 Tracy 835.6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E:--Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + rFEE AMOUNT DUE AMOUNT REMITTED (CKfl I RECEIVED BY DATE PERMIT-NO. -EH 13,24 � ) ry1 I * EH 13-26 1REV.)i H.SS � t�� F� S--!" , Olu 1 7'D 1, 5,