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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 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 District. '/ jl G Job Address `/ 9s �� v AAI AU CityLot Size T I /- �S L '� p Owner's Name U P,1�a I-- 64 A44 s S&AA Phone r Y ►`^�" Contractor's Name bit t V"S H License No. 6q5X1(Clot Llf- 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 O Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications ❑ Public ❑ Other O Delta Depth of Grout Seal Type of Grout z ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by J� 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 ❑ DESTRUCTION ❑ (No septic system permitted If public sewer is , available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feat: Water table depth !C SEPTIC TANK Type/Mfg LCInZAZA A��pacitv-12—,00 No. Compartments PKG. TREATMENT PLT. O or /��f/J / Method of Disposal x Distance to nearest: Well 1 Foundation. 1Q !70� Property Line LEACHING LINENo. & Length of lines — 0 1 length/size FILTER BED' ElDistance to nearest: Well 0— Foundation ,/O Property Line SEEPAGE PITS Depth 2S Size 33 •- ��-�� Number 0 �- SUMPS ❑ Distance to nearest: Well�-�- Foundation/U -- Property Line� f ptf-- 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 rubs 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 not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature certifies tho 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 applicsn st call foeall , ire 'nspeetions. Cc to drawing on reverse side. Signed Title: Date: FOR DEPARTMENT USE ONLY �J AppOication Accepted by zl Date A" its Pit or Grout Inspection by Date Final Inspection by Date 4-3-8 y Additional Comments: O Stk 465-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 9,5201 FEE INFO AMOUNT DUE AMOUNT REMITTED tCK RECEIVED BY DATE PERMIT'No. .EN ns.2r(nev.10/03) 41 S �.�, b0 t D,,..as