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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA � lTelephahe (209) 466-6781 PERMIT EXPIRES 'f YEAR FROM DATE: ISSUED 11 (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 Distric t./ � A Job Address A v ,9 0 `-�(� A/�"' A,,, -I City �'t\M Lot Size �• 22 n e. PM ' _ ! �� Owner's Name AVdC LL Address / V 4 – Phone f T li. k j 4 Contractor k AA W66;MAddress License N4. Phone TYPE OF WELUPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ hk PUMP INSTALLATION ❑ i SYSTEM REPAIR © OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE 1 FOUNDATION a AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED.6SE TYPE OF WELL PROBLEIM AREA 'CONSTRUCTION SPECIFICATIONS ❑ IndustriaN ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications f`l Public ❑ Other F1 Deltai Depth of Grout Seal Type of Grout _ S �* I i Irrigation _..Approx, Depth l I Eastri^ Surface Seal Installed by Repair Work Done ❑ Type of Pump I H`P_;. State Work Done _ (� Well Destruction ❑ Well Diameter Scaling Material Itop 50'1 lw ! Depth I Filler Material tBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION t I 'REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is 1 -1 1 available within 200 feet.) Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: IM •�"' Water table depth SEPTIC TANK ❑ Type/Mfg I Il Capacity No. Compartments PKG. TREATMENT PLT. ❑ t II 1 Method of Disposal Distance to nearest: yell Foundation Property Line LEACHING LINE ❑ No. & Length of lines g 9 t Total length/size FILTER BED ❑ Distance to nearest: Welld Foundation Property Line r SEEPAGE PITS I 1 Depth _ J (Size t _ Number SUMPS Ll Distance to nearest: l!IWeH' Foundation y` Property Line } DISPOSAL PONDS © 1 �� 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 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." 1 11. jl The applica ust call for all req d inspections. Complete drawing on reverse side. CJ Signed X 1 Tit Date: ��0 / ISI it QR DEPARTMENT USE ONLY e52 1 .2 Application Accepted by �`1`� Date rea ` Pit or Grout Inspection by Dlate Final Inspection by ZlnDate 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 2(109, Stk., CA 95201 _f, FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO pp r.EH1 -24 TREY. 51 35 3 EH 144-28 ,�i. 1