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Q / 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.. ! "7�Df' 26C4*�'�j Job Address /� rl?fCZ�/f'4A) �e City S71�A) Lot Size /"-,Y'J fV PM Owner's Name Address 5AV+9 __ Phone 7 Contractor's Name E_L4WD UJAwD _ License No. 42,1-v7 Phone ��- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ _ _SYSTEM.REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK S5:WER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r 1 ❑ 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 H.P. t State Work Done Well Destruction ❑ Well Diameter Sealing Material (top,50') Depth: Filler Material (Belo 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Y DESTRUCTION ❑ (No septic system permitted if public sewer is I available within 200 feet.) . Installation will serve: Residence—"'/ Commercial— Other a Number of living units:--/-- Number of bedrooms + s Character of soil to a depth�f 3 feet: �;1=6:17— :` y-�/-n Water table depth SEPTIC TANK Q' Type/Mfg GL- r &00 G- f Cap city___— No. Compartments d PKG. TREATMENT PLT. ❑ ,.I Method of Disposal ` ') Distance to nearest: Well Foundation 247 Property Line LEACHING LINE & Length of lines Total length/size FILTER BEd ;;IDistance to nearest: Well N -Foundation !aD f. _ Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: - Well Foundation Property Line , DISPOSAL PONDS 71 _ -_ln - L-I C I hereby certify that I have prepared this application and that the workwillbe 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."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." The-applicant must call for a required inspecti B. Complete drawing on reverse side. Signed X�_ Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by'- ` Date 3 Area Pit or Grout Inspection Dat �'�� Final Inspectio b Date a'as Additional Comments: 4 ❑ Stk 466-Ml ❑ Lodi 369-362 Manteca 823-7104 ❑ Tracy 835-6385 Dn Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P. Box 2009, Stk., CA 95201 !so r EE CK F AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT''N0. INFO CASH �- v,�vt ,r�-•� �f�G +EH 13-24(REV.10183) CJ AV u i �$S �•� `r-7-2, EH 14.28 f