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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7' YEARFROM 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.4; /&SOS Job Address 151111111W. City Lot Size PM Owner's Name Address 440 44,'VF.Vl} 2>Z Phone 4777 f f Contractor YL.B /D .5. fi1yC1{Y7 Address. -�-A� -/-of er 57� License Na. �-C1-74 Phone -�3 7/ TYPE OF WELL/PUMP: NEW WELL ❑_ WELL REPLACEMENT C) DESTRUCTION ❑ 4 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP.LINE f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL F • PROBLEM AREA CONSTRUCTION SPECIFICATIONS s I= ❑ Industrial ❑.-Open-Bottom-- 'D Manteca r Dia:of'W&111xcavation Dia. of Well Casing } ❑ Domestic/Private} ❑ Gravel Pack ❑.Tracy. Type of Casing Specifications ❑ Public RT ❑ Other ❑ Delta ''4:Depth of Grout Seal Type of Grout a ET Irrigation ---Approx. Depth . ❑ Eastern Suiface_Seal Installed_by �a Repair Work Done r❑ Type of Purnp H.P. State Work Done Well Destruction ❑ Well Diameter _Sealing-_Material.(top 50') _ _ �' r� cr Depth Filler Material {Below 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r,- available within 200 feet.)-•--�, Installation will serve: Residence Commercial� tither �:---_-_ Number of living units: I Number of bedrooms - �y _ r t J. �-- Character of soil to a depth of 3 feet: 4�AAMZ L J f Water table-depth' i SEPTIC TANK ❑ Type/Mfg -45�r I Sr"7AIG Capacity No. Compartments PKG. TREATMENT PLT. CJ Method,of'Disposal Distance'to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines — 90 Total length/size /99 Xi FILTER BED ❑ Distance to nearest: Well 1_31e_'_ Foundation 3D r 'Property Line -4nQ SEEPAGE PITS ❑ Depth t )- 5ize -)Number. SUMPS ❑ Distance to nearest: Well ;` -Foundation -- Property Line ` DISPOSAL PONDS ❑ ? - t— -AA-! 4 I hereby certify that I have prepared this application and that the work will be done in-accordarice 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 i 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- r tionjaws bf'California." ! The applicant must call for all required inspections. Co plate drawing on reverse side. Signed Title: L, -_ Date: F D RTMENT USE ONLY ^� Application Accepted by �C�.� - 44A he&AACA As, Date Area c I Pit or Grout Inspection by Date Final Inspection by Date �7 Additional Comments: T r kk ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 . __0.Tracy.-83546315 Applicant'-'Return all copies to: Environmental Health Permit/Services 1601 E. Hazekon Ave., P.O. Box 2009, Stk., CA 95201 I -FEEINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERmrr'NO. E + EH EH 14261 EV.t/asl �. — i OJ •`� / —2 Z