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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. Job Address 7,3 CityjAdie Lot Size 6k Ctife-/P PM P Owner's Name C" Paiii$ Address .i.5. 73 L E, Nadkee ed Phone 931-0128 Contractor 5e, (f Address S License No. Phone TYPE OF WELL/PUMP: NEW WELL El ELL REPLACEMENT El DESTRUCTION GI PUMP INSTALLATION Cl SYSTEM REPAIR 0 OTHER 0 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 0 Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Die. of Well Casing El Domestic/Private 0 Gravel Pack C Tracy Type of Casing Specifications O Public C Other CI Delta Depth of Grout Seal Type of Grout 0 Irrigation. _Approx. Depth 0 Eastern Surface Seal Installed by Repair Work Done rl Type of Pump H P State Work Done Well Destruction 0 Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADDITION' DESTRUCTION 0 (No i septic system pe within 200 rmitted if public serer is ava a ble Installation will serve: Residence X Commercial Other P living units: M y xl 0 076,5, 7.3.-24_k I Number of / Number of bedrooms —3 ..,c(9 Character of soil to a depth of 3 feet: Water tadlir cflptri i SEPTIC TANK V Type/Mfg eplACreAT-- Capacity ile.00 No. Compartments 4 PKG. TREATMENT PLT, O Method of Disposal Distance to nearest: Well C20 Foundation Property Line ÷ 2j V _40_ LEACHING LINE X No. & Length of lines / X ;Iv; Total length/size 6/L0114— FILTER BED E Distance to nearest: Well /lo Foundation YO Property Line /2, SEEPAGE PITS ->Ar Depth 0 i Size /0 Number / /4/ SUMPS 0 Distance to nearest: Well /Z4- Foundation 'VC Property Line DISPOSAL PONDS PONDS 0 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 Of 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." The applicant must call for all required ins tions. Complete drawing on reverse side. :5 f i 14-01-4-41.- Signed X 4.4 Title: &taJ"W.A-ye.g Date: At: FOR DEPARTMENT USE ONLY Data r Final Inspection by Application Accepted by Pit or Grout Inspection by C Additional Comments' E Stk 466-6781 0 Lodi 369-3621 Cl Manteca 823-7104 D Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1e01 E. liazetton Ave., P.O. Box 2009, Stk., CA 9520191 + EH 13-24 (REV.', / ei EH 14-28 FEE INFO AMOUgSUE AMOUNT REMITTED Cs-Ca/ CASH RECEIVED BY DATE PERMIT NO. 4 S . CI' in A:ACAO Ikp / / k ko(t; TSS A-1Z li GC---