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• r, ,'T APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT RAC AIZA - " 1601 E. HAZELT ON AVE., STOCKTON, CA EI VEP Telephohe (209) 466-6781 NO V x 6 7990 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) �NVIRONME Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herePE&W A 1. � 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 n Joaquin Local Health District. d Job Address i y C7 5 How P-0 IA N City 5-FCC KrTO1.� Lot Size PM Owner's Name use,/.4_7TAU1.S)on OF 94i>tl LWAddress Phone CHtrFmke_A-L CD �� pp Contractor wag f"'I Azim ia-T Address_=7aF-f t2b icense No. 9 r Phone 8" 2 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES > To 1 DISPOSAL FLD. PROP. LINE VXLA(3LS FOUNDATION > 5O AGRICULTURE WELL uw OTHER WELL U - PITS/SUMPS !5:0 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rr ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing `f ❑ Domestic/Private ��/ ❑ Gravel Pack I-] TracyType of Casing PVL _ Specifications 171 Public 7 )Other M0101100%-1 1 Delta Depth of Grout Seal r S D f-O.S r Type of Groute-Lm I I Irrigation '50.'Approx. Depth I I 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 50') '1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DE=STRUCTION I I INo septic system permitted if public sewer is 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: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line s SEEPAGE PITS I ) Depth Size Number SUMPS LZ 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 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."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 call for all required inspections. Complete drawing on reverse side. J r� Signed X 1— Title: A t�O S J Date: r v FOR D RTIN USE ONLY Application Accepted by Date A Z f Pit or Grout Inspection by Dat e�� y Final Inspection by Date Additional Comments: G✓ 4 l ❑ 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 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. -EH 13-24{REV.r/H5) 6 �l #z- EH 14-M Lh/ 1