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r_ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZELTON 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 Districts. Job Address 33423 kQ 3 5 o /1f,pFtkcl- a City 1rr�� Lot Size PM 4 Owner's Nameet—inf�fIjen 13raJ. (_141 Address i /✓//1��1c`rjV 7/V C, Phone.20'4?- Contractor JAL T Address License No. Phone Lr TYPE OF WELL/PUMP: NEIN 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 El Manteca Dia. of Well Excavation Dia. of Well Casing L ❑ Domestic/Private 13 Gravel Pack ❑Tracy Type of Casing Specifications `\V 7 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout--- I rout_ _I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by - ell 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 K REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is a� available within 200 feat.) Installation will serve: Residence x Commercial^ Other Number of living units: I Number of bedrooms f Character of soil to a depth of 3 feet: Water table depth �0 SEPTIC TANK `J�� Type/Mfg Capacity ©a No. Compartments 2 PKG. TREATMENT PLT.U t Method of Disposal t j Distance to nearest: Well SQ Foundation� Property Line�ZO1 LEACHING LINE `A No. & Length of lines `Z- =90 'J'Total length/size FILTER BED ❑ Distance to nearest: Well_ ._ Foundation Property Line 12 As {— " SEEPAGE PITS I I Depth Size Number IK SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ tr I hereby certify that 1 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 DtItrict. 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, 1 shall not employ any person in 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." The applicant must call for all required inspections. Complete drawing on reverse side. / C ❑ Signed Qy,1 /'r+,/..1 Title: 0 fdg7,g0" Date: FOR DEPARTMENT USE ONLY Application Accepted by 2".t6 7 Date Area 1� Pit or Grout Inspection by Pate Final Inspection by Date Additional Comments: t'1/h0 - i-ZL ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 8{3-7104 ❑ Tracy 8356385 a• Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. INFO Aw �) ` . EH 13-14tREV.,1-51 70 /r" / ^ /�r; dV EH A-Ta VV