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r - 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 (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. � G Ave -C T9 G'-'' Lot Size 46 PM Job Address ity - Owner's Name o A-0 Address Phone Contractor's Name i.2i /�/� License No. ,� �Phone TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑' DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C 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;;r CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. "of Well Casing ❑ Domestic/ Private ❑ Gravel Pack ❑'Tracy ' "" Type of Casing Specifications ❑ Public El Other C1 Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑�Ea-stern,,, 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 50') TYPE OF SEPTIC WORK: NEW INSTALLATION--f—REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation MI I serve: ResidenceCommercial _ Other Number of living units: -I---Numbef of. bedrooms_ Fp"" Character of soil to a depth of 3 feet: .0 /� _ Water table depth SEPTIC TANK IV Type/Mfg"a""""` + Capacity ZmZezV No. Compartments PKG. TREATMENT PLT. ❑ ti Method -of Disposal nearest: Foundation Property Line Distance t Weil i LEACHING LINE ❑ No. & Length_ofaines.: J::_ -AZY,1 Jam- Total length /size. �J FILTER BED �%,��cazl 'Q�Distance,to nearest: wall � p ddtion�o � Property Line ,T ; SEEPAGE PITS ❑ Depth Size "--- °`Number SUMPS Distance tone"arem, Well Foundation Property Line nispnsAl'pnNnS n / 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.+ _ -1Home owner or licensed agent's signature certifies the foi!6wing: ' 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 m the performance of the work for which this permit is issued, ('shall employ persons subject to workman's compensa- tion law's of California." . The applicant must call for all equired inspections. Complete drawing on reverse side. Signed X s ��,/.G� _ Title:- p y Date: Y — ��' FOR DEPARTMENT USE ONLY Application. Accepted by Date # ; 7 900' Area4 111W © g Pit or Grout Inspection by r Date Final Inspection by Date �� o Additional Comments. - - - ❑ Stk 466-6781 ❑ Lodi - 369-3621 ❑ ,Manteca 823-7104 - (]'Tracy, 835-6385 Applicant - Return all copies�t.w-Environmental-Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 # 4 L � FEE INFO AMOUNT DUE AMOUNT REMITTED;, CASH.. RECEIVED BY DATE PERMIT"Np. + EH 13-24 (REV. 10l631 EH 14-28