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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETO,N AVE.,`STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED tY (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.TMs application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. �[_ /� Job Address ZQ:l.Q UTA ✓EpLA-K R JD City L/n!U .u' 1 Lot Size _ PM Owner's Name )--,'Aib Address 40 1r2/ VIA184WIr e" �7X.it _ Phone -J&90gk�3 Contractor Fe• -1-ep �• fNCob Address /eex'.t✓, 4#144_1/IA) License No. �.T S�.1-74 Phone 44-c-.3 7 TYPE OF WELL/PUMP: NEW WELL [ WELL REPLACEMENT ❑ DESTRUCTION 12 / PUMP.-INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE --_-._EOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE I?;i -TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial I ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications D Public G Other ❑ Delta Depth of Grout-Seal _ Type of Grout _ ❑ Irrigation -depth ❑ Eastern Surface Seal Installed by _ Repair Work Done r D 'Type of•Pump H.P. State Work Done Well:bestruction 1 I D Well Diameter Sealing Material (top 501 ! Depth Filler Material (Below 501 LAI TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION D (No septic system permitted if public sewer is U / available within 200 feet.) Installation will serve:r Residence_ Commercial v Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:_nL R -t�PQ-��L Water table depth SEPTIC TANK :r'` z�1' Type/Mfg _1110 4 R•A"- K Capacity 17,-07f) No. Compartments L T PKG. TREATMENT PLT. O Method of Disposal L f 1 Distance to nearest: Well 3 OD j Foundation _ Property Line _ /k LFACHING-LINE' No. & Length of lines 2- 7/ 0.0 / Total length/size 2- �x 7— FILTER-BED FILTER-BED t ❑ Distance to nearest -Well_.'3�'/"> Foundation Property Line y1 SEEPAGE PITS C_J/Depth A2 If _Size�1 2� Number r SUMPS i Wl Distance to nearest: Well_ l/T Foundation-- Property Line • kW-i- DISPOSAL•.PONDS L] 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."Contractors 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 must call for.all re uired inspec' s. Complete drawing on reverse side. Signed X�� r Title: Date: �FONT USE ONLY ' Application-Accepted by _ Date PR or Grout Inspection by Date 16�Final Inspection by DA�In.�Aw ��, Date `b' !� Additional Comments: r ❑ Stk 466-6781 ,, ❑ Lodi 3693621 ❑ 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 CK 0 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. + EH 1324(REV.1 5) FH 14Jri