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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 F_ HAZEL T ON AVE., S OCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 7 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 tt r 4IL&� 64Sr/ � `�� t GQ- — Ciq GOd� Lot Size PM Owner's !Name o�0 Address 127Z) E MA k35P. C( Vt'C h 4. hone j / TN l Contractor s✓ 07�LsTr�>� Address AVIS Ynv� rn r��h ease No_ Phone f)>~ZS'-- o0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS © Industrial ❑ Open Bottom Ul Maroca Dia- of Well Excavation Dia. of Well Casing Q Domestic/Private , tlt'J❑Gravel Pack ❑ Tri g Type of Casin PVC Specifications - �>� S� R lic3� f y er ❑ Deity Depth of Grout Seat Type of Grout ❑ Irrigatio ..f a4pprox. Depth ❑ Easem Surface Seal Installed by •' z-Yid wTs' Repair Work Done ❑ Type of Pump H.P- - 'State Work Done Well Destruction ❑ Well Diameter Seating Material (top 501 Depth Filter Material {below 50' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DES RUCTION ❑ (No septic system permitted if public sewer is available Wthin 200 feet.) Installation wilt 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 `Capaci No. Compartments PKG. TREATMENT PLT. ❑ ' Method of Disposal Distance to nearest: Vlfdi Foundation Property trine LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: VL#eIl Foundation Property Line ''I SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: V4W Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and*w 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 folwAng:"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 teworkman's compensation laws of California." Contractor's-hiring or sub-contracting signature certifies the following: "I certify that in the performance o1*4 work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant t call for all required 'ispec" Co drawing on reverse sid Signed X Tide: e Date: 3 w yS R D PATME SE ONLY Application Accepted b _ .__ �. Date —17 re _._�--- G� Pit or Grout Inspe n by Daae��1:FS Final Inspection __..� Date � Additional Comment 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Marmca 823-7104 I-1 Trac 835-6385 Applicant - Return all copies to: Environmental Health Pewok/Services 1GD1 E_ Hazelt n Ave.. P.O. Bore 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNTft1316tTTED RECEIVED BY DATE PERMIT'NO. INFO CASH EH 13-24 JREV / i� � Ci --_ Ef-It 7191