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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 r PERMIT EXPIRES 9 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of 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. k J0 R _ r Job Address I City Lot Size20 x I 7� PM.� Owner's Name Tt�� " Add ess� ;v Q� k� /Gd'i M. PhoneV2 2zr Comractor ddress / � M License No. 9 b Phone/ -VR�!2 TYPE OF WELL/PUMP:- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATI ❑ SYSTEM REPAIR ❑ `+t OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES DISPOSAL FCD. PROP. LINE f Pt 4 t FOUNDATION! AGRICULTUR ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBL ARE CONSTRUCTION SPECIFICATIONS. a ❑ Industrial ❑ Open Bottom ❑ Mantec Dia. of Well Excavation " ' " Dia. of:k eli Casing ❑ Domestic/Private ❑ Gravel PaWk ❑ Trac Type of Casing Specifications I-] Public Cl Other ❑ elta Depth of Grout Seal Type of Grout 4f I I Irrigation —Approx. Depth I I Eastern SuF a Seal Installed by Repair Work Done ❑ Type of Pump H.P.rt----w•. .!State Work Done- i Well Destruction ❑ Weil Diameter Sealirtg Material (top 501 Depth A(Filler Material (Below 50') TYPE OF SEPTIC WORK; NEW INSTALLATION( RE PAIRlADDITIf)N i 1 DESTRUCTION ( I (No septic system permitted it public sewer is E f / 'available within 200 feet.) Installation will serve: Residence (_►� Commerciale Other t Number of living units:` Number of bedrooms:y_ " ._ t Gharacter of soil to a depth of 3 feet: s .r Water table depth I SEPTIC TANK D Type/Mfg V Capacity 60 No. Compartments PKG. TREATMENT PLT. ❑ _ .;} t .{ ��T Method of Dispos I = Distance to nearest: Well l�j foundation Property Line 74r ' AI LEACHING LINE r J' m�No- & Length of lines _To I length/size l 1 FILTER BED `❑ Distance to nearest:- Well J6y Foundation Property Line • '( ("f r SEEPAGE PITS 1 1 Depth ' Sized _ Number t SUMPS ❑ Distance'to nearest: Well Foundation Property Line ~` DISPOSAL PONDS ;❑ -3 f 1 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: "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 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,1 shall employ persons subject to workman's compensa- tion laws of California." a ` The applicant ust call for required spections. Complete drawing on reverse side. 4 . Signed X Title: Date: ... r k +. F D ENT USE ONLY t 4 A: - t Application Accepted by R ' ` �� pate Area " s Pit or Grout Inspection by Date —11—�7 Final Inspection by Date -44577 Additional Comments: . ❑ Stk 466-6781 ❑ Lodi 369-38521 ❑ 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 FEr INFO AMOUNT DUE AMOUNT REMITTED CASHCK 0 RECEIVED BY DATE PERMIT NO. r EH 13-24 IAEV.rix51 E EH 14-28 O l �