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N 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address Z2 Z 9 fit/. PALO Alf A A ZA9 „ City A/ Lot Size PM Owner's Name L-OAAIE 460A(AlewSK/ Address Phone Contractor_o5TJ2G— LJsmD Address m ISL. SAI License No. O? Y24 Phone - 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ F _ 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 Welltxcavation Dia. of Well Casing F ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing - Specifications ❑ Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout { ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by "r Repair Work Done ❑ Type of Pump H.P.,• State Work Done 1�•/ Well Destruction ❑ Well Diameter 4Sealing Matetial Itop 50'1 Depth Filler Material {Below 501 9 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_ Commercial_ Other Number of living units: Number-of bedrooms F Character of soil to a depth of 3-feet: C Ar" Water table depth Ca SEPTIC TANK ❑ Type/Mfg-,t._ r7,6 s `I&6 Capacity 1— C) No. Compartments PKG. TREATMENT PLT. Method of Disposal Distance to nearest: Well FoundationProperty Line G LEACHING LINE No. & Length of lines!— Total Ian.gth/size O� 7— FILTER FILTER BED ❑ Distance to nearest: Well Foundation : AW 70 Property Line AP� SEEPAGE PITS IA7Depth S/ Size 3 3 Number I SUMPS ❑ Distance to nearest: Well J1112 ' Foundation_ ZD Property Line DISPOSAL PONDS ❑ i 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 must tali for all required inspections. Cam to drawing on reverse side. Signed Title: Date: Z3 OR DEPARTMENT US-E ONLY Application Accepted Date (�`o�o�'��a Area Pit or Grout Inspection by Date !0'0 Final Inspection by 4&W Date ,/"G Additional Comments: 61/ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Haiefton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE F AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. +EH 13-24(REV,t/as) EH 14-126 C �v r