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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 Districts. Job Address /. Al low e-&- SA _ City ; Lot Size PM Owner's Name 1YJeT Z A J&A Address /Am a Phone Contractor ki r7+f __GRA Address / "� Y [7a __ License No.3773SS Phone33 fl-V? � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.)d0 PROP. LINE Za FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /L Dia. of Well Casing Domestic/Private -)W Gravel Pack ❑ Tracy Type of Casingpzlc Specifications i FI Public Ll Other (7) Delta Depth of Grout Sealy Type of Grout <4^,t0-:r I < t0- I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by cg4C A Repair Work Done ❑ Type of Pump 3440dN H.P. / State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 { Depth Filler Material (Below 50') S TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I "DESTRUCTION-I-I-INo-septic-system permitted if public sewer is available within 200 feei.F Installation.willserve:__Residence_.„rCommercial,_- Other__ Number of living units: Number of bedrooms Character of soil to a depth of.3 feet: Water table depth ` o SEPTIC TANK ❑ Type/Mfg ` Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size - S FILTER SED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size _ Number SUMPS Ll Distance to nearest: Well 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. I 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 hifing or sub-contracting signature certifies the following: "I certify that in the performance of the work fpr 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. p Signed X �"�^"'� • A41— Title: _13%4jr%. ..r Date: FOR DEPARTMENT USE ONLY l Application Accepted by 'T / Date � Area Pit or i•o Inspection by r Data�� Final Inspection bye\ y Date 2 Additional Comments: ❑ Sik 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 95291 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMITNo. INFO ) r EH1324 IREV.I/n sl •� 1 15 { EH 14-28 �Q / Qq