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F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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. 18b2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address n tJ City STtiCifChn Lot Size PM Owner's Name _ Soo—.0—AAI ChrOyzwll`ayk - _ Address 0% Phone L 6!7 1 Contractor _L�ttsctysa ��f �1i� __Address 0 Ut LA r:Q 6.1404 License No. _ �l�x/Y_ .3u Phone *5 6 71'a y"t TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REQ IR ❑ OTHER J$ Seit IQv,rt`+ DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES ISO' DISPOSAL FLD. PROP. LINE FOUNDATION �— AGRICULTURE WELL -- OTHER WELL__ PITS/SUMPS O INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 171 Domestic/Private ❑ Gravel Pack L1Tracy Type of Casing Specifications F] Public )(Other a->A f! Delta Qepth of Gr� eel Type of Grout C vv%o I 1 Irrigation Y-Approx. Depth I 1 Eastern eal I by 1> Repair Work Done ❑ ST p `��mp r H,P. State Work Donq — Weif•Destruction Diameter 5 Sealing Material (top50') CPysc-1 a1'O 434,51, Depth s8 a Filler Material Welow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION E I DESTRUCTION l I (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 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 clearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS 0 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." Contractor's hiring or sub-contracting signature i 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." rr! 1_ The applicant must call for all re wired i spections. Complete drawing on reverse Jside. -Se Signed X_ �l� Title: �.r(.t1V(i LQ YJ+ Date FOR DEPARTMENT USE ONLY Application Accepted by C Date — Area Pit or Grout Inspection by -- Date I%L Final Inspection by Date 19V V_ Additional Comments: Sik 466=6a�!T ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tra6y 835-6385 pplicant - Return all copies to: Environmental Health Permit/Services 1601 E. Haielton Ave., P.O. Box 2009, Stk., CA 95201 440L wo FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMI'r'No.- INFO CASH + EH 13-24(REV.t/K5) ` OWE:, EH 14-29 «��.��