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L� 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 r. (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. �1 , , AcbC 1 N Job Address /�1• � �.r Ciry�7! ZT�e/YDS/JSL/l`ot Size PM ^7 Owner's Name �"+a cA KIT t End rN fl"id�ddress ` a `Ll ll 11 dN� Phone — Contractor 0Qo2 YA1'IF- Address NC_t,3 1 � {'tcX License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WE L REPLACEMENT DESTRUCTION ❑ rr - PUMP INSTALLATION ❑ STEM REP ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARX601 CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca We Excavation Dia. of Well Casing 1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracyf Casi Specifications L 71 Public ❑ Other ❑ Deltaof Grout eal Type of Grout_ I I Irrigation —Approx. Depth I I Easterne Seal Insta d by _ Repair Work Done ❑ Type of Pump .PState Work Done Well Destruction ❑ Well Diameter Sea (top 50'1 4 Depth Fillelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 fee[.) ` Installation will serve: Resjdence X Commercial_ Other Number of living units: _l Number of e/ddd1roo Character of soil to a depth of 3 fee, � tF[O Aco Water table depth //(AR' SEPTIC TANK ❑ Type/Mfg E. &o Q 41? Capacity Idad No. Compartments 2— PKG. TREATMENT PLT. ❑ � n�� ,_ Method of Disposal � N Distance to nearest: Welles Foundation� Property Line LEACHING LINE No. 8 Length of lines .2� Total length/size _ FILTER BED ❑ Distance to nares, Well��`F Foundation OO'f Property Line SEEPAGE PITS I 1 Depth Size .,2.Xl Number V r ^^^ SUMPS L�Distance to nearest: Well Foundation Property Line 0 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 r, rules 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 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 t call for a iequ� d pections. Complete drawing on7r'9/terse side. Signed — �1� Title: y(.fl7iLeti� Date: r R DE ky plica io ccepta�d,^yv'�y Date `-' Area or ro n W "'� ate 1—_7 / Final Inspection by ,,t — Date I v Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 V INFO AMOUNT DUE AM NT REMITTED CCK RECEIVED BY DATE �(�PyE,RMIT NO. ` + EH 13-24(AW,1ix st 0, 4V(/ fyy U •�./QjLo EH 11-25 _ _jy -I T