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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address S Q City 15� T7<AZ Lot Size 1-85'X 1 14 PM Owner's Name 6ZVCKTVfJ A AW ff=:CA1 Address 42-11 60RIONA00 5' d Phone A462,e9,?7 7- Contractor FLo`/6 G- kJoob Address_7 A6 AD,�[ f --A7—Ave License No. Phone 44, TYPE OF WELL/PUMP: NEW WELL. ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 M Public {=1 Other Ll Delta Depth of Grout Seal Type of Grout --- I I Irrigation —.-Approx. Depth I I Eastern Surface Seal installed by Repair Work Done D Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material atop 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITIDNK DESTRUCTION I I (No s itted if public sewer is available within 200,feet.) Installation will serve: Residence_ Commercial_ Other WL4r Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: l"?L Ay Water table depth SEPTIC TANK ❑ Type/Mfgmal t9T.1Ars Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well _ Foundation Property Line LEACHING LINE Cr?' No. & Length of lines I-3-C Total length/size FILTER BED ❑ Distance to nearest: Well .SI2/ Foundation ZrOi Property Line .� Phi4-GTL_1� SEEPAGE PITS I Depth .2i z _ Size 4_g..�� Number f SUMPS Ll Distance to"nearest: Well– /o D Foundation Property Line f 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 Di§trict. 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."Contractors 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 must call for all required inspections. Complete drawing on reverse side. Signed X Title: C@�/l�t� Date: 9f7 !?1-- FOR DEPARTMENT USE ONLY Application Accepted by �^�� Date 1��1�~ ' Area Pit or Grout Inspection by Date Final Inspection by Date 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 2409, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY D TE PERMIT NO. INFO j C H r.EH1324IREV.t/n511 01C) ) r r, �} 17� EH 14-28 /// lr/ �✓