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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 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/� / f �{ Job Address 7 �^' !7 y - �-/ ✓�� City �� Lot Size PM +rte y� uf i i Owner's Name [ li"� (It. L V Address Z 3 . i Lf 0&, 0 Phone Contractor _ AAK&C-4-if 041E Address 3990 License No.ZSq 14Y3 Phone_'566+'44 0 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER L ES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICUL)(1 OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREAN SPE7by ❑ Industrial ❑ Open Bottom ❑ Manteca avatioDia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Specifications ❑ Public ❑ Other ❑ Delta SealType of Grout ❑ Irrigation _Approx. Depth ❑ Eastern stalled Repair Work Done ❑ Type of Pump H.P. _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 4� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑- REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence 1-Commercial '-Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: i rw Water table depth I SEPTIC TANK ❑ T ^ ype/N'�1l� Capacity No. Compartment: PKG. TREATMENT PLT. ❑ f t Method of DisposalI.' Distance to nearest: Well-.----- — foundation-'-- """"Property Line j: l LEACHING LINE ❑ No. & Len th of lines } 9 { Total IengthYsize FILTER BED ❑ Distanaao nearest: Well Foundation Pro�erty Line F . SEEPAGE PITS ❑ Depth Size f Number SUMPS ❑ Distance to nearest: Well ---FoundationProperty Line DISPOSAL PONDS ❑ I hereby certify that 1 have prepared thig application and,4hat the work will.be done in accordance with San Joagpin county ordinances, state laws, and;t_ rules and regulations of the San Joaquin Local Health-Distilct "' -_-="" - � . �' - Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work far which this permit is issued, I shall nod 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." �9 The applicant mu t c II for all required inspections. Complete drawing on reverse side. Signed X Title: y /' ,? 7 Date: }' FOR DEPARTMENT USE ONLYS � 4 Application Accepted by Date r rea Q Pit or Grout Inspection by Date _ nal Inspection by N i Date Additional Comments: e rr� oalx ✓ r ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-Z4IREV.i/951 &7_ EH 14-28 I