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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL•HEALTH DISTRICT 1601 E. HAZET O,N AVE., STOCKTON, CA Telephone (2N) 466-6781 PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED Ly (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 Ryles and Regulations of the San Joaquin Local Health District Job Address Y©'11-0 &ZAy�p wX 12.p City C_/AIU1-tiJ Lot Size PM Owner's Name ":/ 1)" t"b 1 44WAAL_L .Address A1WUW7F AIRY .';WA1 Phone Contractor FLItTP 5• Wcd D Address I&dC�J, License No. Y.7.LQX__74 Phone 44-C-3 97Z TYPE,OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ / PUMP-INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C :.r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE —.EO.UNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE I? `!'TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ID Industrial I ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout,Seal Type of Grout ❑ Irrigation _Approx.'Depth ❑ Eastern Surface Seal Installed by Repair Work Done r ❑ •y Type of-Pump _ H.P. State Work Done Well:Destruction I ❑ Well Diameter Sealing Material (top 50') r :,, ! Depth Filter Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system per if public sewer is U / available within 200 feet.) Installation will serve:( Residence_ Commercial v Other Number of living units: "Number of bedrooms Character of soil to a depth�f 3 feet:_Ls"!/-15AA 4L Water table depth SEPTIC TANK ter'`'r Od' Type/Mfg Capacity )7,-1X1( No. Compartments _A-_ T PKG. TREATMENT PLT.❑ Method of Disposal L ! i Distance to nearest: Well 'A O&! Foundation Property Line LG LEACHING-LINE- W111No. & Length of lines Z—'"/ 010 _ Total length/size �� x 7— FILTER BED FILTERBED /Y' ❑ Distance to nearest: —WAIT ,� I?z�Foundation Property Line SEEPAGE PITS M Depth 1 D Size Y X l 'L r Number r SUMPS Lel Distance to nearest: Well 15489 Foundation— Property Line DISPOSAL.PONDS ❑ 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 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 lbws of California." �, s The appli;ant must call for.all re~uired inspec o s. Complete drawing on reverse side. 1 ' Signed Title: �0��/i-• Date: YS Rd `1 l FOR DEPART ENT USE ONLY 0�� Date i � / a 1 Area �� C App }ion-A;cepted by Pk or Grout Inspection by Date Final Inspection by LDate Additional Co41nts: ❑ Stk• 466.6781 ., ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-6385 Applicant=Retum all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ,INFO AMOUNT DUE AMOUNT REMITTED 'CASH CK 0 RECEIVED BY DATE PERMIT"N0. t EH 13-241REV.t/a5)