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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 hereb described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. IOU for well/pump and ft Rules and Regulations of the San Joaquin Local Health District. {� I [� Job Address I + 1 �d A-Lio ldo c GU City Lot Size A0 4 4, PM Owner's Nome U v�_AII?Y7?►w3� Address R;. Phone Contractor �d dress NI1r�f License No. 3Jr�� Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F PROP. LINE FOUNDATION AGRICULTURE WELL WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONST lO1V SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia.of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications El Public El Other ❑ Del Depth of Grout Seal Type of Grout ❑ Irrigation �Approx. Depth tom Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diam Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION PAIR/ADDITION ET DESTRUCTION © (No septic system permitted if pub€'ie sewer is ,�,rI available within 200 feet.) Installation will serve: Residence_ Commercial z Other a f ` Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: r Water table depth SEPTIC TANK LI—Typemi p Capsehy__`-6 C- No. Compartments PKG. TREATMENT PLT. L� Method of Disposal Distance to nearest: Well_ 11 - Foundation RN € Property Line LEACHING LINE 04-7Vo. & Length of lines �C Total length/size Q r FILTER BED --'Distance to nearest: Well O l Foundation Property Line SEEPAGE PITS 5-�Depth 12 '_ Sire - It Number_ SUMPS 0 Distance to nearest Wall17d l Foundation Property Line DISPOSAL PONDS Cl 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 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 parson in such manner as to become subject to workman's compensation laws of CaWornia."Contractoes 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 persong subject to workman's compensa- tion laws of California." The applicant must call fo all reAulred inspections. Complete drawing on reverse side. Signed)t`� Title: MAJA Date: y y oF FOR DEPARTMIEW USE ONLY Application Accepted by Date 4/*IV-AreaAD Pit or Grout Inspection by Date Final Inspectlon by AN Date Additional Comments: , ❑ Stk 466-Ml ❑ Lodi 389.3821 ❑ Manteca 823-7104 ❑Tracy 83fr M Applicant- Return all copies to: Environmental Health Permit/Services 1001 E. Haetton Ave., P.O. Box 2009, Stk., CA 9fii201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 6Y , /DATE �PERMIT'NO. +ENVF7 9;w 13-24 IREV.1?e W L� EH 14.20 1