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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address � � LrJAL c e City .5'Y .tJ Lot Size-AL',�EfQG-E PM Owner's Name AAJ&e ZZAJ190 ,.._ Address S Phone WF Contractor tc'Z-O �0 WWO2 Address �tl A.17E�B ,G�r- i4rr'E License No, � .1-7 Phone ` S 397/ 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 CON STRUCTION"SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing. ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other rI,, 1-7 Delta Depth of Grout Seal Type of Graut ` I I Irrigation Approx. Depth, I I Eastern Surface Seal Installed by 'Repair Work Done ❑ Type of PumpH,P. . State Work Done .` I Well Destruction ❑ Well Diameter Sealing Material- Depth aterial Depth Filler Material (Below 50'1 _ TYPE OF SEPTIC WORK: NEW.INSTALLATION i 1 REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve:, Residence w'' Commercial_ Other f Number of " livin units: u _ , -a- 1 g , . - �. Nmber of bedrooms Character of soil to a depth of 3 feet:n !!l .G _ Water table depth SEPTIC TANK ❑ Type/Mfg; c-X S—, I A-Ic- Capacity No. Compartments + I PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line l.9 LEACHING LINE f � E`�L'Y No. & Length of lines Total'length/size FILTER BED ❑ Distance to nearest: Well�Qr Foundation 7�` Property Line SEEPAS GE,P,ITi�f Depth jNumber Size �'i r�^ j �.., SUMPS ❑ Distance to nearest: Wel! 1007 Foundation Property Line t10 DISPOSAL PONDS ❑ m i 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 A 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 became subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature e p ` certifies the following:"I certify that in therformance of the work for which-this-permit is issued, I-shall employ'persons subject to workman's compensa- [ tion laws of California." .I 1 The applicant must call for all required inspections. Complete drawing on reverse side. �y I Signed X :D % _ _ Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date !' Area Pit or Grout Inspection by Date Final Inspection by Date��a 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 OUNT DUE AMOUNT REMITTED CK INFO RECEIVED BY DATE PERMIT'NO. +,EH1 -24{AEV.iins7 EM 4 / '� # � � • '� /�-p L ar�b `