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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby 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. 1$62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. A Job Address AA AZO Y4 PO SA &Z City '445�.4LOA/' Lot Size AS ACE K .2- PM r .. 1d u i a��r7 N T T i Address SACC Phone Owner's Name 4 e s Contractor l)iYYhVA' ¢ ;f~ Address 0100A nM ✓ `t L cense'No.A�4�> -0 Phone ..TYPE OF WECL'IPUMP:"°""�-"� NEW WELL"❑""'""�"�'�'^WECrREPLACEMENT^❑—`- DESTFi0CTI0N ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES` DISPOSAL FLD. `� PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE' F WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑'Open`Bottom ❑ Manteca Dia- of Well Excavation Dia. i f Wel! Casing t Type of Casing— Public Specifications ❑ Domestic/Private ❑ Gravel.,Pack ❑ Tracy yp g ... - (� ("1 Public ❑•Other, C1 Delta Depth of Grout Seal . � 4 f� Type of Grout I Irrigation —"Approx. Depth , I 1 Eastern R Surface Seal installed by' w ^- ( H.P. State Work Done_ 1 - - Repair Work Done [� Type of Pump ` � Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below,501 r ; TYPE OF SEPTIC WORK: NEW INSTALLATION I:l REPAIR/ADDITIONDESTRUCTION t I (No septic system permitted if public sewer is available within 200 feet.) i Installation will serve: Residence Commercial_ Other Number of living units: f Number of bedrooms -� 1 Character of soil to a depth of 3 feet: kld?.*vy A&4Ai Water table depth sn� lxoa n s � SEPTIC TANK � C7 'Type/Mfg e C Capacity Na. Gampartment's PKG. TREATMENT PLT" ❑ _ h Method of Disposal$ I Distance to nearest: Well jD � Foundation AS� Property Line L R - 6S' Total length/sizef �p t1`ACHING LINE � . No. & Length of lines � r FILTER BED ❑ Distance to nearest:;' ,Well_"._lam` Foundation Property LineyQ SEEPAGE PITS ['l Depth �8�"'tom "Size �� _ Number I SUMPS le Distance to nearest: Well Foundation �� Property Line -70r t DISPOSAL PONDS ❑' s I hereby certify that I have prepared this application and that the.work will be done in accordance with Sari Joaquin county ordinances, state laws, and rules and regulations'of the San Joaquin Local Health District. . . { r 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." _4t } The applicant-must call for all required inspections. Complete drawing on reverse side; Signed X Title: Date: t .' F EPARTMENT USE ONLY !" Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date___—. Additional Comments: ❑ 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 K 0 "RECEIVED BY DATE PERMIT'NO. # INFO a EH13-24 tREV.V/H 51 %g EH i4-28