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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephohe (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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 s�Aa b], M—W IX gg City F 7726.! Lot Size 1g5-X I q4 PM Owner's Name 57`DCK7??n1 ig/4 c,�u� Address x'1-11 60 P-4 NA PL _f.- _S'TK✓ Phone �Q8'ZZ Contractor a LO YD 4_ Al 0'e 7J Address -I-Al.,- AAAAAb—'_-L,8,9A7—Av4 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ . PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 17 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 ❑ Manteca Dia- of Well Excavation -_ Dia. of Well Casing _ LJ Domestic/Private it Gravel Pack ❑ Tracy Type of Casing Specifications * Public i1 Other L 1 Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done '3 Type of Pump H.P. __._ State Work Done __ C Well Destruction :1 Well Diameter Sealing Material (top 50') Depth _____ Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTAtAATION I I REPAIR/ADDITION JK DESTRUCTION I ! INo s fitted if public sewer is o vailable within eet.1 Installation will serve: Residence _ Commercial _ Othere-wup- Number of living units: __W_ Number of bedrooms Character of soil to a depth of 3 feet: - _-C'LJa_Y _- —.._..... Water table depth SEPTIC TANK ❑ Type/Mtq zt-X 197-mea Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal _ Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines 5 '70 . /-b�; I-31 Total length/size FILTER BED U Distance to nearest: Well -412 Foundation SOS Property Line S� SEEPAGE PITS itr Depth ____Size ¢8�� __ __—. Number SUMPS Ll distance to"nearest: Well /00 Foundation A2.0 Property Line DISPOSAL PONDS ❑ �XfiCx 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 Di§trict. 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."Contractors hiring or sub-contracting signature certifies the fallowing: "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 all required inspections. Complete drawing on reverse side. Signed X 4��ZE J,I Title: Date: n.,. _ - FOR DEPARTMENT USE ONLY Application Accepted by Date `\�l�1 � Area�4� Pit or Grout Inspection by Date Final Inspection by Date �Z Additional Comments: U Stk 4666781 Ci Lodi 369-3621 U Manteca 823-7104 ❑ Tracy B35-6385 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 RECEIVED BY D TE PERMIT NO. . EH 1324 rREv.liner INFO /14 , 0 -0 H ` �� EH 14-20