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itasr, APPLICATION FOR PERMIT ,me SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6761 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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 of No. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address SAIZO Al hilWY City Ii� TFC.✓ Lot Size /$SX 12 4 PM 8APT7S7- 2.0 A77 Owner's Name 57tDCC rDn1 cutiB-GAoe Address 41-1/ L+I Zar AIADO S1Xa1 Phone /ttL Contractor FLOYb 9. 6Jdi jJ Address 7 Al, ADEe-AAAL7-Av6 License No. 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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications UI Public ❑ Other fl Delta Depth of Grout Seal Type of Grout I I Inigatlen _..Approx. Depth I I &Intern Surface Baal Installed by - O Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destructlon ❑ Well Diameter Sealing Materiel Itop 501 Depth Filler Material f8elow 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No s ystem.p fitted if pubtic sewer is varlable within 2 mt.) Installation will serve: Residence_ Commercial_ Other 011 oer Number of living units: Number of bedrooms C '-- - Character of soil to a depth of 3 feet: 0-1 Ay Water table depth SEPTIC TANK ❑ Type/Mfg A-A( 14 YIAICty. Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE f No. & Length of lines 4-10 . /-4-C /-31' Total length/size J4& .3 �) FILTER BED ❑ Distance to nearest: Well 1�t, Foundation d"0 z Property line ' Attt3/ SEEPAGE PITS (K Depth AS' Size ¢Q Number / SUMPS Ll Distance to nearest: Well /00 r Foundation /.� r Property Line_S" DISPOSAL PONDS ❑ �7fkLtLa( 1 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 D3trict. 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 laws of California."Contractor's hiring or subcontracting 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 must call for all required inspections. Complete drawing on reverse side. 'Signed Xs" > f (/J Title: Date: /I- 9- yy Q1FOb DEPARTMENT USE ONLY �1 Application Accepted by `M>Il- `^^"' Date 10` 1°'' Area d tt Pit or Grout Inspection by Date Final Inspection by Data 4Z. Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8361KI85 `,-t„•o Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �` . 917 6/1 FEE AMOUNT DUE AMOUNT REMTED RECEIVED eY DTE PERMIT-NO. INFO CH SEH 13.24 n!". /14 too -701 7 EH 14 n t/ h