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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. Job Address -2 13 7 AV City 4-7/C Lot Size_�� 5V.3d0 PM Owner's Name Phone She Contractor's Name W, Aeldode-I-X—A" VS6541,C License No. Phone ft 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 ❑ 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. . . State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet./ Installation will serve: Residence X�_ Commercial_ Other Number of living units: _ Number of bedrooms 3 f Character of soil to a depth of 3 feet:CZIrj1 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �1 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines Total length/size 3740 FILTER BED ❑ Distance to nearest: Well Jd P Foundation 30 � Property Line_�O' � SEEPAGE PITS ❑ Depth /0 Size yfC r_X 6P Number SUMPS J° Distance to nearest: : Well Foundation lBa r _ Property Line 3e ' DISPOSAL PONDS ❑ 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 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 t tali for all required inspections. Complete drawing on reverse side. Signed Title: — Date: 0 Ir FOR DEPARTMENT USE ONLY Application Accepted by Date -.2– Area 1J z Pit or Grout Inspection by Date Final Inspection by i ./t7/Yi? Date 1 / 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. Hazekon Ave., P.O. Box 2009, Stk., CA 95201 FEE CK 4 INFOAMOUNT DUE AMOUNT REMITTED CAS RECEIVED 9Y DATE PERMIT'NO. + EH 1324(REV '� .101831 c F p EH W28 J -7_6 4 �