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A PLICATION FOR PERMIT SAN JAQUIN LOCAL HEALTH DISTRICT 1601 E:'H AZtLTON 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. s. rl �f r Job Address _J r l r '"' L City Lot Size �G �S PM Owner's Name Zl�� "' — '7 Address Wof /2-4-- Phone� z" ' ! � Contractor Address I License No. Phone PE OF WELL/PUMP: ;NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPA ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LI S DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTUR WELL OTHER WELL—PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CON UCTION SPECIFICATIONS ❑ Industria! - C7 Open Bottom -- rye❑ Manteca-�. — D' . of W 4 Excavation ,r Dia. of Well Casing ❑ Domestic/Private fa Gravel Pack ❑ Tracy ype of Casin Specifications F1 Public # M Other � ❑ Delta Depth of Grout S I Type of Grout I I irrigation _.-Approx. Depth 1a Eastern Surface Seal Install. y Repair Work Done ❑ Type of Pump P. S to Work Done Well Destruction ❑ Well Diameter' ` Sealing Material )top 5D'I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION 11 (No septic system permitted if public sewer is available within 200 feet.) n , Installation will serve:, Residence Commercial_ Other Number of living units: --L.— Number of bedrooms 3 � � 1 . Character of soil to a depth of 3.feet: Water table depth y SEPTIC TANKr~ El SEPTIC Capacity I2��T No. Compartments PKG. TREATMENT PLT. ❑ F� Method of Disposal •. Distance to nearest: Well ndation Property Line w .. f LEACHING LINE Ln No. & Length of lines —Total length/size 15 p FILTER BED ❑ Distance to nearest: Well �.—.Foundation /1�— Property Line- s SEEPAGE PITS { 'Depth Size Number SUMPS L1 Distance to nearest: Well' Ifi IF Foundation /+ :Property Line ._J` ` DISPOSAL PONDS ❑ " 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 Dittrict.' 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 w to become subject'tb Workman's compensation laws of California."Contractor's Hiring or sub-contracting.signatu certifies the following: '9 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workmanacompensa- tion laws of California." The appllc4nh must call for regtlred inspections. Complete drawing-on reverse side , r Signed Titles f�� Date: Of F, DEPARTMENT USE ONLY Ap licatian Accepted by Date Area , /�///�` Dati3�� i r Grout Inspection by Data/ V U _..�Final Inspection b y Additional Comments:' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6365 { Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,.CA 95201 fwq FEE A OUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT'NO. t(eA o.-O INFO // nil* �^ +.EH 13-241REV.i/A51 1�*70. �J 7O •� b` U CI 4 �l D r 1()""6 EH 14-28