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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 Sen 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. "Foo, Job Address City S 14.- Lot Size PM 2b4*—r l9yWFL6L6VIOwner's NameA7ei Address AA1 fig_ Phone Contractor .c/�- Address I.WSl J`�Q�(.'��/ e No. 30SLZI Phon 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 ❑ 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 509 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system.permitted 8 public sewer is \ Installation will serve: Residence_ Commercial ZOther available within 200 feet.) ' Number of living units: -A- Number of bedrooms 1 Character of soil to a depth of 3 feet: c-� Water table depth _c SEPTIC TANK 91 Type/Mfg Ae apecity�I ' )_� No. Compartments PKG. TREATMENT PLT.❑ t Method of Disposal , Distance to nearest: Well Foundation_40 f Property Line 47 LEACHING LINE Er�No. 8 Length of lines IF ��Totaall length/size FILTER BED Cl Distance to nearest: Well 75' Foundation�J�Property Line SEEPAGE PITS Depth . Size hituber I �,r� SUMPS ❑ Distance to nearest: Well_J.3 r Foundation a2.3 y 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 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 o all wired inspections. Complete drawing on reverse side. 9 ) Signed K_V Title: to 0i r,..a'�2 ^ -•t �T.Date: �� FOR DEPARTMENT USE ONLY 7A� Applicatiioon�cce�pnte�d by / Date rea V Pitor R htsdsekl �ar1 + pr(b rains r1P� r� Flnal Inspectto y e Additional Comments: . L1U r`J I I r N Iv 1>d Zllkk 4 6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O cy 835 385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazahon Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. � ql I1 AI IarV � nn '