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3 APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 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/of 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. t Q Job Address , Lou I s e �`!� City (TMA Lot Size +�C�S PM i 3 3S Owner's Name AIVN L, M Address Phone 1 Contractor ' fq `A[Jfc'{te Address r e License No. 293-7/3 Phone "Z ly a TYPE OF WELL/PUMP: w NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:`SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL- OTHER WI=LL PITS/SUMPS INTENDED USE TYPEOF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open, Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing - Specifications E M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout r j I I Irrigation _..Approx. Depth 1 I Eastern Surface Seal Installed by f - Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Ito; 50' t Depth 1A Filler Material {Belo I v TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION Pr DESTRUCTION I i iNo septic system permitted if public sewer is <_ ,� availabl within 200 feet.) �- Installation will serve: Residence Commercial_ Other t Number of living units: Number of bedrooms: edrooms ''f 1 r �! J Character of soil to a depth� of 3 feet: ' Water table depth EP_TIC,TANK ❑ Type/Mfg - f Capacity No. Compartments y PKG. TREATMENT PLT. ❑ ..... �" Method of Disposal Distance to nearest: -WelFoundation Property Line f � � LEACHING LINE ]W No- & Length of lines Total length/size I FILTER BEDf ❑ Distance to nearest: Well Foundation Property Line , t I i SEEPAGE PI TSS I I-I Depth i Sixe 1 Number SUMPS LV Distance to nearest: Well I F,00undation Property Line DISPOSAL PONDS-19-----4 f f I hereby certify that I have prepared this application and that the world 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.. ', ies„the following:"di fy that in the performance of the work for which this permit is issued, I shall not employ any person in such rnannar 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 i hich this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must-call-for-all-required in pactions. Complete drawing on reverse side. 4 Signed X �"• Title: Date: FOR DEPARTMENT USE ONLY > Application Accepted by "!._ �'' Date Area Pit or Grout Inspection by Date --.,_�f} Final Inspection by } Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑ Tracy 835-6385 CW ' 95201 . ____.___ .._... Applicant - Return all copies to: Environmental Health Permit/Services,1601 E. Hazelton Ave., P.O. Box 2409, Stk., CA + �— FEE AMOUNT DUE AMOUNT REMITTED CK ASH RECEIVED BY DATE PERMIT'NO. IWO �j *-?I EH 13.24(REV.1/H b) (/� 70 �,_' EH 14-26