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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209} 466-6781 , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) a: Application is heF.eby 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/purrip and the Rules and Regulations of the San Joaquin Local Health District. tit / Job Address �.� �-S� E f Akp_/,c�QNG city 0406 . Lot Size 20 IpCAWS PM Owner's Name 11/� 4012111.S' Address ��s�' �A�ZII�EY Phone g^ C3an'tractor`t"IAI(ZYIISh 4 iY�1S AddressP.O. License No.,�5FV343 Phone toQ 6 TYPE OF WELL/PUMP: � NEW WELL ElWELL iREPL`ACEMEjVTT❑ e.4 ,'REST,RUCTION..❑ .t PU)MP-INSTALLATION-❑ SYSTEM REPAI A� r OTHER D � D$TANCE TO NEAREST: SEPTIC TANK._ SEWER LINES, DISPOSAL LD. PROP. LAE FOUNDATION AGRICULTURE WELL OTHER WELPITS/SUMPS I— -A J 1 to L<1 INTEND USE TYPE OF WELL Pi OBhEM ARECONSTRUCTION SPECIFICATIONS.1 t ix ' ❑Industrial ❑ Open Bottom ❑ Manteca)-i -Dia. of Well Excavation k;"' Dia. of Well Casing " 01 omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing i + Specification ❑Public ❑ Other I ❑ Delta Depth of Gro Sealer " Type of Grout 1 r L J I ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by l ♦-� Repair Work Done ❑ Type of Pump H.P. State Work Dongt= i Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth I Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ■ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is t j available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: __L_ Number of bedrooms 3 Character of soil to a depth of 3 feet: Water table depth r 1 SEPTIC TANK ■ Type/Mfg Capacity_ 1!3 OD No. Compartments PKG. TREATMENT PLT. EJ Wr Method of Disposal t Distance-to nearest: Well 100 Foundation 3 Q/ _Property Line _SQ" ._ t k LEACHING LINE' " ■ No. & Length of lines /^ r Total length/size O� � FILTER BED ❑ Distance to nearest: Well Foundation Property Line r, C SEEPAGE PITS Depth 2 r Size 4� E Number ' SUMPS. ❑ Distance to nearest: Well Foundation Property Line L DISPOSAL PONDS ❑ 7 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."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." i The applicant must call for all required inspections. Com late drawing on reverse side. Signed X Title: .e^.1 Date: FOR DEPARTMENT USE ONLY Application Accepted by^ Date 113— Area d } r Pit Grout Inspection by/ Date Final Inspection by Additional Comments: 1 ❑ 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 j FEE INFO AMOUNT DUE AMOUNT REMITTED CK ASH RECEIVED BY DATE PERMIT'NO. tEH 13-24)REV. /it 5) /' - EH 14-28 � �'� 1 -e a (p ^ �