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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (2091 466-6781 ? PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) a 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. } ` Job Address 1427 -z Y Va:iWJAL -- City La ZZ Lot Size PM Owner's Name Address 4/A9,E• / wezzo R4 -- Phone 16"30 ! Contractor g Address License No. '1rv� I Phone TYPE OF WELL/PUMP:.. NEW WELL ❑ WELL REPLACEMENT,❑ DESTRUCTIONA I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications \� f'1 Public P Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump �f_._� H.P. State Work Done C Well Destruction r U Well Diametl� — Sealing Material (top 501 r Depth filler Material 18elow 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION 1 1 DESTRUCTION I l INo septic system permitted if public sewer is 1 available within 200 fe.et.l 1 Installation will serve' Residence�� Commercial_ Other ` \ s i Y Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:! Water table depth = �' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments \\\ PKG. TREATMENT,PLT. ❑ IMethod of Disposal f t Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/site 'f1 FILTER BED © Distance to nearest: Well Foundation Property Line i SEEPAGE PITS I. I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 taws 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 re gwr ctions. Complete drawing on re 7L_735 Signed_X tii )'� �_l -Date:-- �1 �-�8 t" F6R PARTIWENT USE ONLY Application Accepted by m 'Date. G7 "I3- Area 410 Pit or Grout Inspection by Date Final Inspection by Date 119 VS, Additional Camme�lts: r~ O y❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Vanteca -7104 ❑ Tracy 835-6385 { Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 to FEE AMOUNT DUE , AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO, INFO CASH +.EH 13-21(REV.t i x 5) - EH 14-28 60 - , 4