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New 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address .5Y3?,0 Al. WW 99 City 9 TIC.✓ Lot Size /SSX 1 24 PM Pns7' Owner's Name 5717CKTD wJ 18ll �'-uc+R-C-/1 Address 4Z// LrI 9,O NADO r Ste✓ Phone Contractor i1i 6 G1on2Address _7 ,,/. AD EC.BeALTAv6 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout — I I Irrigation Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRiADDITION DESTRUCTION 1 (Nos r�� fitted if public sewer is C available within 2110 Lrai Installation will Serve: Residence_ Commercial_ Other K a� Number of living units: LQ_ Number of bedrooms ------ - Character of soil to a depth of 3 feet: 0-1 A Y Water table depth SEPTIC TANK ❑ Type/Mfg _rrX{4 7'iwa Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line — t LEACHING LINE IRI No. 8 Length of lines /-3S Total length/size FILTER BED ❑ Distance to nearest: Well .S"J� Foundation 3©x Property Line -f x PkCTLv SEEPAGE PITS IM' Depth 2S� Size 4,2r Number SUMPS Ll Distance to nearest: Well /oo ' Foundation Property Line -rte DISPOSAL PONDS ❑ EXrYGrLy( 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 subcontracting 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 allrequiredinspections. Complete drawing on reverse side. (- Signed X ��.. L�4F Title: [��l�zn.E Date: yL \ FOR DEPARTMENT USE ONLY 9 Application Accepted by X51-- ` • s Date \\_10` "� Area Pit or Grout Inspection by Date Final Inspection by t Date Q� Additional Comments: ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED C H RECEIVED BV D TE PERMIT NO. INFO /--C /T) A ��//y . EH 1121 IREy.iixsi � N /14 , 00 // '� 7[/ V �'/ / EH t