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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 0 Local Health District. Job Address _�� 17"00 10'V ,�_Q42Ai n-/2 _SAW 7 6 Citys � Lot Size 17 X 4/x10 PM Owner's Name EAZC-411,1.4 Address �� Phone ',o P�r(f— Contractor's Name /o ��/�f� '��'Cxil:�i License No. —c7VL3 Phone A4 YK6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION . .-_ AGRICULTURE WELL OTHER WELL PITS/SUMPS C INTENDED USE TYPE OF WELL 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS- 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Z7- ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump J- H.P. ; State Work Done Well Destruction ElWell DiameterfSealing Material (top 50') f Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑` REPAIR/ADDITION 4 DESTRUCTION ❑ (No septic system permitted if public sewer is ,available within 200 feet.I Installation will serve: Residence_ Commercial _Other A9.07— (� Number of living units: Ar Number of bedrooms Character of soil to a depth of 3 feet: fL f Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments tj PKG. TREATMENT PLT. ❑ '~' .. i Method of Disposal ' Distance to nearest: Well"- Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: x Well`'` Foundation Property Line SEEPAGE PITS Depth, .Z6 2,57 _Size 4' Number 3 SUMPS ElDistance to nearest: Well OSsO 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 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." Contractors 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 applica st call for all required inspections. Complete drawing on reverse 'de. f Signed Title: - Date: FOR DEPARTMENT USE ONLY o Application Accepted by `� 14—_-. it Date. Area ZI _ Pit or Grout Inspection by Date'7 Final Inspection by Date 'off Additional Comments: 1411ii6s rO 1611-T /� _ ��Cl _ ks ❑ Stk 4664781 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`IVO. + EH 13-24(REV.10!83) 6 EH 14-28 V " l