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e) s3 c_4_ _ u1 APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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. Q Job Address ja.�d ��Ass�v g s y� ,.o.�# 73 City Y/1G Lot Size PM Owner's Name Ayy4rC"Ar o r Address A `B^AF S X R C• Phone Contractor /�� ' SvN Address ��^ Lvlr` f�~�'7 ✓fi License No. one TYPE ..'„ WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f PUMP INSTALLATION-0 w...._._.. SYST€A4-A€PAIR_.0 _. __ THER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLPITS/SyMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Ind4strial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wol Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other ❑ Delta - -13epth-of-Grout Seal- Type of Grout _ o I I Irrigation __Approx. Depth I I Eastern Surface Seal Installed by _ O EJ Type of Well Repair Destuct Destructionrk Done El Well Diameter $satin X State,V1�ork Donk V p.Mat etibi OpP1 w� Depth Fi er Material IBelow)50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADD1TtON DESTRUCTION 1-4 (Nes6ptic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence-I— Commercial_ Other Number of living units: Number of-bedrooms- Character f_bedroom&Character of soil to a depth of 3 feet: L fh T AmAA1 Water t*le depth %70� SEPTIC TANK ❑ Type/Mfg Capacity No. Cori partments PKG. TREATMENT PLT. ❑ Methodof Disposal Distance to nearest: ',Nell Foundation Property LineT .. LEACHING LINE. ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to'nearest: Well Foundation Property Line v" ► �1 SEEPAGE PITS I I Depth � Size 6 ,K (j z X�'0' _ Number t,- SUMPS �I Distance to nearest: Well 4-0 Wi4C Foundation Property Line�(*� DISPOSAL PONDS ❑ `, I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaq county orc`,nces, state laws, and rules and regulations of the San Joaquin Local Health Di$trict. ' Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for'which this pe�,pit is issued, I shall not employ any person in such manner as to become,4bfect to workman's,compensation laws of GelifQF[iie„ Ger+ttee . 's hiring or stjCi 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 workman's compensa- tion laws of California." ) The applicant must call for all required inspections. Complete drawing on reverse side. i Signed X Title: Date: 1 FOR DEPARTMENT USE ONLY Application Accepted by Date Area 22 Pit or Grout Inspection by Date Final Inspection by Z4Zf Date lei Additional Comrnents: 1 _.., _Tracy_.. __.5-6385 ._:..L1..tnAs�1.__�.. .1._,_.._ ._C�..�tltL?r Seca._823-7104. !] _ 83 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE L� PERMIT'NO. + EH 13.241REV.i/Hs) —7V9r�� r(7 —aL f EH 14-2e