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fz � * APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES J YEAR FROM DATE ISSUED;r.. r ' (Complete in Triplicate) Application is hereby made tolthe 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. .t Job Address �,00o �l yl'�� City Lot Size PM Naval Espid�! �f! yVyokutsSfov,�fvYt -0991 Owner's Name Address Phone k �v8�f old Asc.fartirn Contractor I vv�'Y 6nV` WVF%�s Address ��Y �F �i License No. S!1 �lto Phone4q* �Z;-� TYPE OF WELL/PUMP: 41 NEW WELL ❑ WELL AEPLACEMENT ❑ DESTRUCTION ❑ f / PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X 50l1 ��f S(xJ 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 lit Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingSpecifications awof-W15% 7 Public H Other ❑ Delta Depth of Grout Seal 2� Type of Grout 4 I I IrrigationIL_Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ .F Well Destruction ❑ Well Diameter Sealing Material atop 501 Depth Filler Material {Below 501 TYPE Of SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION { I DESTRUCTION l I [No septic system permitted if public sewer is it available within 200 feet.) Q Installation will serve: Residence_ Commercial_ Other 0 Number of living units: $ Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ ' Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line L LEACHING LINE ❑ i No. & Length of lines Total length/size FILTER'BED ❑ Distance to nearest: ' Well Foundation Property Line SEEPAGE PITS I I l] Depth Size _ Number SUMPS L Distance to nearest: Well Foundation Property Line 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." 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." i Theapplicant must call for all required-inspections. Complete drawing on reverse side. 1 Signed X Title: O "e v r Date: Zilf — 07 { OR DEPARTMENT USE ONLY Application Accepted by I Date {2- (tCY — Area Pit or Grout Inspection by Date Final Inspection by Date. Additional Comments: I� ❑ 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 2009, Stk., CA 95201 C� VaDws lin acvwrc.0 '�v- � 40, FEE AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT'NO. kINFO . EH 13-24(REV.r/H5YI � . b EH 14-2e „II - 6