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v I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 F 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I Job Address .31 A 3 110 S rVy Ad City )rX09CV Lot Size PM v Owner's Name r Y/tC rK Address �j�3 Ii0 �O lire{ Phone 3��✓` 3r+rg Contractor 7lVrilp/Y it 50ry Address AVZ ��u� e7 �� License No.!yWJP91Phone Jr"i?J y °J TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION-'LJ-- 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 ❑ Domesticl Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout -.--- I I Irrigation --Approx. Depth I I Eastern -Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done E Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') - TYPE OF SEPTIC WORK: NEW INSTALLATION i l REPAIR/ADDITION LV, DESTRUCTION l I INo septic system permitted if public sewer is " available within 200 feet.) Installation will serve: Residence ' Commercial Other Number of.living units: _L_ Number of bedrooms r Character of soil to a depth of 3 feet: J-0.4,W Water table depth O i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. f l Method of Disposal Distance to nearest: Well Foundation Property Line t LEACHING LINE V No. & Length of lines �PC" Total length/size A 00, y FILTER BED ❑ Distance to nearest: Well 1490 Foundation,�a Property Line 10 F SEEPAGE PITS I I Depth Size Number SUMPS L7 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r 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 mus call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: y�-� 9CP FOR DEPARTMENT USE ONLY 4*1 Application Accepted by Date 1' 90 Area 216 r Pit or Grout Inspection by Date Final Inspection by Date_ C7 3 Additional Comments: Ll 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 RECEIVED KO- INFO SH RECEIVED BY DATE PERMIT'NO. I p' ' + EH13241REV.rills: 7Q-� 7®- � 15-60 Ek 14-29 1