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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. 1651 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, Job Address l , .SD 1 City Lot size 170' 'L PM /r Owner's Name L�iFRUS %�AWWAOAA Address 2.!7 S'��ONAMECs &4-Er Phone ";, O Contractor's Name License No. P o TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL_5 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 El Other I❑ Delta Depth of Grout Seal Type of Grout 1 ❑ Irrigation -Approx. Depth © Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done Well Destruction L� Well Diameter Sealing Material (top 501 lJ Depth Filler Material (Below 501 �I /TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is \j available within 200 feet.) jInstallation will serve: Residence � Commercial T th r' Number of living units:4— Number of bedrooms 1i l'1 i t Character of soil to a depth of 3 feet: Water table depth 111 4SEPTIC TANK1Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ R Method of Disposal `�5J Distance to nearest: Well Foundation Property Line r i LEACHING LINE rJtZNo. &Length of lines f -�� "}' •Total length/size �, 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line Q ; SEEPAGE PITS ❑ Depth Size Number y SUMPS ❑ Distance to nearest:;` Well Foundation Property Line l 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 District. - - Z. j 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 Iaws 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 Cal'lfom" _ The applicant fo I inspections. Complete drawing on reverse side. Signed Title: �.� Date: FOR DEP4RTMENT USE ONLYNor �_ 1 Application Accepted by `''' Date 93 Area a 1 Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: ❑ Stk 466-Ml ❑ Lodi 369-3621 ❑ Manteca W-7104" racy 835mm Applicant- Return all copies to: Environmental Health Permit/Services 1601 Ldr. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT`NO. + EH 13-24 IREV.10M � �"�S o 4D13 EH 14-26