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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 '� � � -7 AZVO9,40P__2 D _ City S-17eAf Lot Size gS j 0 ' PM Owner's Name C,4Ale.eN C6 rO1�S_VI1�.Address Phone (- Contractor G'Ld y > G-. f.JOVD Address 7 AJ, ADEL.l3EP_7",4f/� License No. �4 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout I I irrigation .Approx. Depth I I 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 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I Wo septic system permitted if public sewer is / available within 200 feet) Installation will serve: Residence?/ Commercial_ Other /977- Number of living units: __/_ Number of bedrooms Z N Character of soil to a depth of 3 feet: e4A Water table depth SEPTIC TANK ❑ Type/Mfg Capacity /2-m a _ No. Compartments �- PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well_ �O Foundation 167 Property Line LEACHING LINE ❑ No. & Length of lines �X f�T'/AJG Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size C—lU_V n/C" Number SUMPS Ll Distance to nearest: Well Foundation 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: "1 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 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 all required inspections. Complete drawing on reverse side. Signed X � Title: _ t Date: "1�j �4ta FD&DEPARTMENT USE ONLY Application Accepted by 4Date Area zz Pit or Grout Inspection by Date Final Inspection by� ,SS>T�. Date /6 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 INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'ND. +.EH13-241flEV.tix51 0 0 GO-1a F