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APPLICATION FOR PERMIT SAN JOAQUIN 'LOCAL{HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-67$1 PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED in (Complete in Triplicate) Application is hereby made to the San Jdaquin 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 LocalHealthDistrict: Job Address Ci t ~LoSize tY � PM Owner's Name YIE 4 -Address JVAAI eV,64 S R. AADf., Phone Address ContractorH'(� �8l►CST. 'T w �� 1�_ t.l�e`• License No.. �� Phone �3 TYPE OF WELL/PUMP: NEW WELL ❑ `WELL REPEACEMENT'❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j`INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS- 1-1 PECIFICATIONS- ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ;Cl.Romestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing . Specifications ❑hPublic ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑irrigation �4pprox."Depth ❑ Eastern Surface Seal Installed by I Repair Work Done ❑ Type of Pump H. State Work Done Well Destruction ? ❑ Well Diameter Sealing Material (top 50') l ,Depth ! Filler Material (Below 501 l TYPE OF SEPTIC WORK: NEW INSTALLATION•10- REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 20.0 feet.) a Installation will serve: Residence Commercial—" AOther PA ZR y A,4.-A.Al t ? Number of living units: Number of bedrooms f s Character of soil to a depth of 3 feet: DW table depth �h r SEPTIC TANK ❑ .Type/Mfg! O&AfLL Capacity 7 No. Compartments + PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation' Property Lirie LEACHING LINE ❑ No. & Length of lines b X S S 'Notal length/size- FILTER ength/size FILTER BED distance to nearest: WellFoundation s2 S4= Property Line SEEPAGE PITSpl�fistce Size Number SUMPS to nearest:- R Well ? Foundation Property Line DISPOSAL PONDS J F- ` �, fl - 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 agen't'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 menner as to become subject to workman's compensation laws of California."Contractors:hiring.or sub-contracting signature certifies the following:"I certify t at i—`F'n the serforman ee of the work for which this perm) its issued', I'shail employ persons subject to workrrian's compensa= tion laws of California." The applicant rDust call for all required inspections. Complete drawing on reverse side. y ' Signed Title: OR PARTMENT USE ONLY Application Accepted by _ o, . a ,. Date a _-bS rea ` Pit or Grout Inspection by" Date Final Inspection by ate — Additional Comments: - �-• ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6M Applicant- Return all copies to:'Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE " AMOUNT REMITTED RECEIVED BY DATE PERMIT NO ". . INFO- H # +EH13-241REV.i/s 5) EH 14-26 � I