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APPLICATION FOR PERMIT "AN JOAQUIN LOCAL HEALTH DISTRh-f 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 13 S-2 e , M 1 ) I 'Q a c d I?d. City s A C1e-1bf/ Lot Size i 2 4n PM C �f go9) Owner's Name Ay e!E/ ✓e S,4 Address S d H+-i C Phone e16 S' - 7 2 D Contractor.ow" e' Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEYENT ❑ 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 * Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I 1 Irrigation —.Approx. Depth 1 I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done kA Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I IT REPAIR/ADDITION 6( DESTRUCTION I I INo septic system permitted if public sewer is - available within 200 feet.) Installation will serve: Residence_ Com ddl_ Other 0 + Number of living units: _ Number of bedr a Character of soil to a depth of 3 feet: -r iF e i ue�o Water table depth SEPTIC TANK JK Type/Mfg CAH. G arP S�Q Capacity 26 No. Compartments PKG. TREATMENT PLT. ❑ r r Method of Disposal Distance to nearest: Well Jyl Foundation !y Property Line y__ 1 LEACHING LINE ❑ No. & Length of lines C X 7 S /.// Total le h/size / y1 r i FILTER BED ❑ Distance to nearest. Well� Foundation 2�tty Line `2 v all SEEPAGE PITS I I Depth- 2 � Size ev Z Number f s SUMPS LlDistance to nearest: Well SSD Foundation AGO 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 Di3trict. 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 As of California." Contractor 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." 7� - The applic t ust ca or fired inspections. Complete drawing on reverse side. Signed r - Title: ff 171/72 e- 1 r Date: If F D HTMENT USE ONLY 4pplication Accepted by Date Area /Q Pit or Grout Inspection by Date }�� Final Inspection by QQ Date/a m ., Additional Comments: t4 Wc"f4 t�U.Crt2 1t-�JC ❑ Stk 466-6791 ❑ Lodi 369-3621 ❑ Manteca OM-7104 ❑ Trac /C� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Haz It on Ave., P.O. Box 2009, Stk..,, C/A 95201 Qof6f C.t�r ��La&zF'y�l�p NFO FEEAMOUNT DUE AMOUNT REMITTED K RECEIVED By DATE PERMIT'NO. ( YJ�jdy CCC . EH 111-24 mEV. +n 5i EH 1;.2a � ♦ d �j 21 j H S S��S� g..