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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 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. i Job Address 30/000 ffi95504Y AW. City TAY Lot Size PM 1)( Owner's Name A/��CC 0 G�t�!'�f Address Aor A s S.T T. R• �' Phone X-75-45-#769 � Q Contractor /�ilV Address AVA �L vC vM Ale" License No. Phone Jr.Zl'S�.Zi TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARFTST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE-WELtt-'- "tjTWffi tIWELt - 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 F] Public Cl Other F1 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_ 1 Well Destruction ❑ Well Diameter Sealing Material (top 501 W Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW IN'&TALLAcTION-{ 1- REPAIR/ADDITION.1/I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve`. Residence-Z— Commercial_ Other G Number of living units: Number of bedrooms 4 Character of soil to a depth of 3 feet: %P*ta -te►jle depth SEPTIC TANK ❑ ,Type/Mfg _ _ b• Capacity No. Compartments PKG. TREATMENT PL74❑ � Method of Disposal Distance to near�stt, Well Foundation Property Line i LEACHING LINE ❑ No. & Lengtlt of.lines Total length/size FILTER BED ❑ Distance to,pearelt:� Well Foundation Property Line SEEPAGE PITS I I Depth Size'XL I17 X 10 Number SUMPS lCl Distance to nearest: Well Foundation Property Line Jr" DISPOSAL PONDS .` ❑ 1 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 N rules and regulations of the San Joaquin Local Health Diltrict. (� 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, 1 shall not A\ employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's 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 mu call for all required inspections. GorApI*,drauuing on reverse side. Signed X Title: Date: dy-x '�9 OR DEP RTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection b 6Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 _-Applicant--Return.afl copies-to.-EnvironmentaLR"Ith Permit/Services 1601 E..Hazelton Ave.,P.O._Box.2009,-Stk.,.CA.95201. ...: t . FEE W99 INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. + EH 14-28IREV.iix5l �/Z C31 0