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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone,(209) 466-6781 PERMIT EXPIRES.I 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 Ryles and Regulations of the San Joaquin Local Health District. f Job Address Ae Ze/ .d• /tJ/i9.i ely J City YAG Lot Size PM Owner's Name I,G�KeA W wee'a/ Address 0~7'r Phone Contractor / /q/Y aiY I'AW Address 461,Ar !0 �A a License No. SPV/ - Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Q �: Y -�- PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE,, I 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 f Q Public "fl Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---L4pprox. Depth O.Eastern Surface Seal Installed by V Repair Work Done ❑ Type of Pump H.P. State Work Done , J Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth i. /Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION XI REPAIR/ADDITION'D DESTRUCTION ❑ Mo septic system permitted if public sewer is available within 200 feet.l. Installation will serve: Residence_/ Commercial— Other Number of living units: Number of bedrooms 3 Character of soil to a depth of 3 feet:_SAY 4e/5rir1 Water table depth SEPTIC TANK 41 Type/Mfg 4r#*ST Opacity No. Compartments PKG. TREATMENT PLT. ❑ "': Method of Disposal' Distance to nearest: Well-,FoundationProperty Line l LEACHING LINE 2'• No. & Length of lines 3 ' 9G � Total length/size FILTER BED ❑ Distance to nearest: Well /4y0 Foundation Property Line SEEPAGE PITS ❑ Depth�•rR Site"4 Number F ` SUMPS ,q ❑ Distance to nearest: /Well oundatlon'_'PrSperty"C1 DISPOSAL PONDS ❑ hereby certify that I have,prepared this application and that the work will be done in accordance with San Joaquin county ordinances, tate)aws and rules and regulations of tkb 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 pe,rmit is issued;l 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 laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X A4 ''`.Title: Date: b'L 1 ` F R DEPARTMENT USE ONLY Application Accepted by ° / Date Area P7 I Pit or Grout Inspection by Date Final Inspection by Date Add-itional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY. DATE: ;PERMiT"NO INFO CASH + EH 13-244REV.t/a57 EH 14-26 Y !