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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 Local Health District. Job Address __9!V7�r_ __177/CNE GLt I-AJ City Sy—KAJ Lot Size PM Owner's Name _a-uOAJO ! Address S14-",04" Phone � 9f,6 T Contractor 4a E. lu'cW1a i' Address_Z AIA A7>C�L� ��d License No. 6�1Sa7� Phone 5=397/ TYPE OF WELL/PUMP: NEW WELL ❑ W WELL REPLACEMENT U DESTRUCTION ❑ -PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER n 4 � DISTANCE TO NEAREST: SEPTIC TANK; SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private El Gravel Pack LlTracy Type of Casing Specifications _ l•1 Public r I Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation __Approx, Depth 1i Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Jo Depth Filler Material (Below 501 S TYPE OF SEPTIC WORK:' NEW.INSTAL LATION4 REPAIR/ADDITION I I DESTRUCTION f I (No septic system permitted if public sewer is t available within 200 feet.) Installation will serve: Residence P/I Commercial` Other Number`f living units: ,-t— Number of bedrooms `Character of soil to a depth f 3 feet: 'f Water table depth SEPTIC TANK : .,* Type/Mfg- ('"r pY-C Capacity 1 BOO No. Compartments �- ! r PKG. TREATMENT PLT. ❑'' f Method of Disposal 'Dis'tante to nearest: Well'. /gV Foundation /4 Property Line 3 LEACHING LINE M "Nl&. &-L-ength of lines Z - Total length/size 70 ` FILTER BED ❑ •Distance to nearest: Well i0a47 Foundation 2-C?l Property Line 7--5'� SEEPAGE PITS I Depth 'lsS fi -Size 3,(,v ` _ Number SUMPS 0 Distance to nearest: Well 5O r Foundation FO 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 f 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,']shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required ins ctions. Complete drawing on reverse side. ' Signed X _ „-_ Title: Date: i DEPARTMENT USE ONLY , w . - Application Accepted bye - Date Area ,. i or Grout Inspection by Date Final Inspection b Date t � v Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104--'El Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 EE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATES PERMIT'NO. +.EH14-24{REV.i/e 51 { //r / �O EH 14-28 / 'f f ig