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APPLICAT1rON FOR PERMIT ♦`b, SAN JOAQUIN L6CAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 it PERMIT EXPIRES TYEAR FROM DATE ISSUED (c mplete 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 A 6 2 3 `7;L 1, Ai'�Z° City "' 'r"+ Lot Size �� PM Owner's Name L7E'a'!}cyl�tA' TYv'S7 'ot� Address 5,:9'01 C0I60C'& Rd, t lvele$r b Phone ��' $-StCo Contractor IF AV Md/,- -6 %n/r Address 4'0039 61,1 wq l✓A. License No. Phone 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing • Specifications 1`7 Public F Other Ll Delta Depth of Grout Seal Type of Grout _ I I Irrigation —Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION A REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted it,public sewer is W available within 200 feet.) ' Installation will serve: Residence_ Commercial_ Other Mtl6.4 f Nir Number of living units: Number of bedrooms Character of.soil to a depth of 3 feet: X-'V C1 Water table depth SEPTIC TANK 8 Type/Mfg FP_( L Capacity LA No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well -A-00-A-00Foundation �C � Property Line 'Fee LEACHING LINE 0 No. & Length of lines � �� Total length/size FILTER BED y ❑Npristance to nearest: Well oaf' Foundation .le Property Line zf SEEPAGE PITS f I Depth Size Number 'L SUMPSI a Distance to nearest: Well it C 0 Foundation 9", Property Line 9e-V DISPOSAL-FONDS ❑ 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." Contractor's hiring or subcontracting 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 all required inspections. Complete drawing on reverse side. Signed X 4 Title: Date: s/6 `~ /O On FOR DEPARTMENT USE ONLY Application Accepted by Date `� Area , Pit or Grout Inspection by Date Final Inspection by Date t� 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 INFO AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT'NO. S ♦ EH13-241kEV,tins) I 1�� /G — I EH 14-2e t -!u