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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 Rules and Regulations of the San Joaquin Local Health District. ' / LOT �� 2e-�'6 �� 9 City -S f"' Lot Size /4�'�S PM Job Address Owner's Name L�ALLF,Y BZA' AAddress /.3 « A) /7'tA 'JU 57y �rEe� Phone Contr4qtor's Name G d G ' �s7� License No. i��rY7G Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑. SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLb. PROP. LINE \(� FOUNDATION AGRICULTURE WELL .OTHER WELL PITS/SUMPS 1\�\ INTENDED USE _ TYPE-OFWELLPROBLEM AREA CONSTRUCTION SPECIFICATIONS? ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ 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 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic within emitted if public sewelis 0 feet.1 Installation will serve: Residence Y� Commercial_ Other Number of living units: Number oqff!bedrooms�- Charact r of soil to a dept/�,of 3 feet: _a��er�r -Water table depth SEPTIC TANK F' Type/Mfg L11,4_ Capacity`,7i0'a No. Compartments -_ PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation A0 Property Line 91O51' - LEACHING LINE No. & Length of lines /doeq Total length/size 151&k 2�- � FILTER BED ❑ Distance to nearest: Well -'rde"V Foundation yrs Property Line ARB �-C 7 Size Number SEEPAGE PITS Depth �/ �.z�-�— � i SUMPS ❑ Distance to nearest: Well JG(a-`_ Foundation JA Property Line DISPOSAL PONDS ❑ 1 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 call for for al -1 pections. C plete drawing on reverse side. Signed X_ Title: t � 4 Date: 7-le FOR DEPARTMENT USE ONLY �_`1� Date 1'YL—E3� Area a Application Accepted by S„, h�� (2--)r Grout Inspection by �R Date i ll- Final Inspection by Additional Comments: ❑ Stk 4666781 ❑ Lodi 369-3621 ❑ Manteca 823-7104: - ❑ Tracy 8355-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.Ha±elton Ave., P.O. Box 2DO9, Stk., CA 96201 ffEEDUE AMOUNT REMITTED CASF{ RECEIVED BY DATE n-79 « EH 13-24 IREv.101831 - ��-/EsS1 � EH 1425