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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZELTON AVE., STOCKTON, CA r 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City `� TdA)Lot Size PM Owner's Name AY-1VA f� _ Address Phone Contractor &eeeX&/-f.;Td.fl fAddress Q/VrJzl�a A License No. r Phone '4LD TYPE OF WELL/PUMP: NEW WELL ❑A. WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ A+ SYSTEM REPAIR ❑ OTHER 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. i PROP. LINE FOUNDATION 'a'. AGRICULTURE WELL OTHER WELL PITS/SUMPS _ 'INTENDED USE TYPE OF WELL. PROBLEM AREA,a CONSTRUCTION SPECIFICATIONS ❑ Industria! ❑ Open Bottom--s Cl Manteca Dia- of Well Excavation Dia.-of Well Casing- L) Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Casing Specifications M Public n Other ! {1 Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work pone_ Well Destruction El- Well Diameter Sealing Material (top 50'1 f' I Depth c "+�-� Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I.] REPAIR/ADDITION DESTRUCTION yY (No-septic system permitted if P public sewer.is f available within 200 feet. Installation will'serve: Residence A� Commercial. `. Other i y f Number of living units: Number of bedrooms 1rrrr,��111+11111 j Character of soil to a depth of 3 feet:` .r e.. ' 4 ti�` I Water table depth 4 SEPTIC TANK I r Type/Mfg, :�]��' G��.,�c ATE PKG. TREATMENT PLT. ❑ l.� _� k� Capacity a No. Compartments Method of Disposal Distance to nearest: Well .fib Fc 4 Property Line .2 LEACHING LINEg A _ �� ' Total length/size 7r Na. & Len th of lines g FILTER BED ❑ Distance to nearest: Well So a Foundation T, - , e Property Line 10 " SEEPAGE PITS Depth _ 2S',. Size .33`• t 4 Number'' _Z i SUMPS +t` Ll Distance to nearest: Well / { —t./. i -->�_ Found'a'tion D•. Property Line DISPOSAL PONDS: ❑ y { _ - 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: employ an I g: "I certify that in the performance of the`work for which this permit is issued, I shalt not p Y y 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 Ifo rwhich 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 Title: I tit Date: - S FOR P RTMENT USE ONLY Application Accepted by �/ Datef / _ r Area i or Gro Inspection by Date S• Final Inspection by , Date S �, Additional Comments: 0 Stk 466-6781 ❑'L-odi 369-3621 p Manteca -823-7104''4 0-Tracy 835`6385 Applicant - Return a'If copies io: Environmental Health Permit/Services�1601 E. Haielton Ave. .P.O. Box-2009, Stk., CA 95201 FEE 1 1 INFO AMOUNT DUE lr AMOUNT REMITTED w.CASH RECEIVED 8Y DATE ' PERMIT NO. a . � ;.EH 13-24(REV.F/N 51 4 41 AA . _ _ ..s.-- EH 14-26 ../l. „�,z•-.r.,.. .5tq`-��...t<�, 23 `►I E+0