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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES TYEAR 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 C 77 City_-57271t . Lot Size/3S JX 2—'� _ PM Owner's Name 7eAlA11S `bE4_A4 A76 Address 3i4srr - Phone F3/- / Contractor_r-l- ._1c3aop Address / Al. AA_--1.;,F 27- * License No.4/v� Phone r TYPE OF WELL/PUMP: NEW WELL. ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION❑ ,aSYSTEM REPAIR ❑ OTHER ❑ I , DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES,--. DISPOSAL'FLD. Y`PAOP. LINE' t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i; ci INTENDED;USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial = + ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑,G_ravel.Pack _ 11) Tracy-.r r Type of Casing Specifications (`l Public f)-Other FI Depth of Grout Seal ' Type of Grout I I Irrigation• -- Approxi Depth l 1 Eastern Surface Seal Installed by _ Fepair'Work'-Done ❑ -Type of Pump H.P. State Work Done Well Destruction 'LO. ' Well Diameter Sealing Material (top 501 `l �w Depth Filler Material-(Below 50 _ !, TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION D(l DESTRUCTION I I (No.septic system permitted if public sewer is available witt in,200 fe_ef.1 Installation will serve: Residence Commercial Other -� Number of living units:' Number of bedrooms !J Character of soil to a-depth of 3 feet:' r'----. Water table depth SEPTIC TANK ( Typ0mfg-.Q-JW a /Z0 GL- Capacity No. Compartments Zr PKG. TREATMENT PLT'❑ _ 18� �X t STS"« Method of Disposal ��.�.�. t /D 'i Distancenearest: Well " - 5`�`— Foundation ' Property Line S to r ' LEACHING LINE No. & Length of lines Total length/size } pX r FILTER BED L1Distance to nearest: Well Foundation _319 Property Line SEEPAGE PITS AI DepthX' S r Size Number SUMPS ❑ Distance to nearest: Well �— Foundation 7r r Property Line Z� r DISPOSAL PONDS ❑ 1 -� 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." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: - ti Date: FOR DEPARTMENT USE ONLY Application Accepted by H Date `� � � Area Pit or Grout Inspection by r Date Final Inspection by Date Additional Comments ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT NO. Ac ♦.EH 13-24(REV. O EH 14-26 ! / Pr