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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT SCA,/VNED 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. / f Job Address /"2 Z -n �C /�� /aCJG City L OVI Lot Size Pm _ Owner's Name ll.)-G &e Akl-LA-4-.e AddressPhone a �1 94YYLY _ 36-*y�j6 - Contractor Address DATE _—ZLly—C License No.s7^1 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Ll 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-- --iMOBLEM AREA CONSTRUCTION SPECIFICAT.MS _ Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public n Other 11 Delta Depth of Grout Seal Type of Grout--_ I I Irrigation __ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done II Type of Pump H. P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Li Commercial _ Other Number of living units: �_ Number of bedrooms Character of soil to a depth of 3 feet:—,�f�ELY�,r CJi�>1 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. [_l Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L -No. & Length of lines s�J Total length/size FILTER BED Ll Distance to nearest: Well _Ad> Foundation 2 0 Property Line /D J SEEPAGE PITS iN" Depths / _Size / Number Xd SUMPS 1.1Distance to nearest: Well r Foundation Sy' Property Line /D C 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 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 Califomia." 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 must call for all re fired inspections. Complete drawing on reverse side. Signed X Title: L�A- A� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 74 �. - [i Area ��" Pt Date Final Inspection _- Additional Comments: Cl ❑ 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 + EH 13-24 (REV. i e5i EH 14-2a FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIpT'NNO. /o id