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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {2W 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Dag —tr Q/D- Lp 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. Job Address Lot Size A6 f mac, PM P Owner's NameiC W�a� �• _ Address - 57 PAS Phone CA . .r Contractor P Address 40 A/ 06&-0 T�-L icense N0Ad__AZ5'�30,6 Phone - .6 TYPE OF WELL/PUMP: NEW WELL L3-- WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Cl SYSTEM REPAIR O OTHER ❑ DISTANCE TO NEAREST: SEPTIC `1ANK 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 O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (`I'Public Ll Other 11 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal installed by _ 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 I I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve:- -Residence�—t ommerciat=-Other Number of living units: Number of bedrooms 3 r Character of soil to a depth of 3 feet: �� Water table depth SEPTIC TANK J& Type/Mf6 _ Capacity _)200 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal r Distance to nearest: Well 00f Foundation 4Q Property Line -rr- r LEACHING LINE No. & Length of lines 3 Total length/size_ I FILTER BED ❑ Distance to nearest: Well C)17t_ Foundation 1"0'f__ Property Linecif -vr 2�h7 _ SEEPAGE PITS Iv✓/Depth ._-_Size ,___� Number SUMPS L1 Distance to nearest: Well Foundation 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 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: "1 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 rust call f allrequired inspect' ns. Complete drawing on r verse side. Signed X 1 Title: ��f"�/e Date: CTRTMENT USE ONLY � Q Application Accepted by 1 - r, Date L'` 7 Area �9 t �C X t Pit or Grout Inspection by Final Ins_ e pection by Date Additional Comments:f_ ~ O Stk 466-6781 O Lodi 369-3621 O Manteca 823-7104 O Tracy B35-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE OUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO AM/y� � / `\ . EH13241NEV.ii7+51 rthf(/ V CO��u { �� EH 74-28