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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT "f3 3 e/' 1601 E. HAZEL T ON AVE., STOCKTON, CA A Telephone (209) 466-6781 PERMIT EXPIRES T 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. Job Address City of Size / aft re. PM_L1— Owner's Name Address � w� �PGe- i.+Y'. �l A Phone Contractor n/IA Address License No. Phone T WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public Ll Other Cl Delta Depth of Grout Seal Type of Grout _ I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is Q .� available within 200 feet.) Installation will serve: Residence= Commercial_ Other / r Number of living units: Number of b dr ortls See c,I,-►+fir+j b e W� Character of soil to a depth of 3 feet: b "'' Water table depth 1� SEPTIC TANK ElType/Mfg "' M apacity _l��MM L� No. Compartments r PKG. TREATMENT PLT. E) .1 Method of Disp s9l Distance to nearest: Well MKT Foundation /D Property Line LEACHING LINE ❑ No. & Length of lines VFW f-rTotal length/size FILTER BED ❑ Distance to nearest: Well Im Foundation Property Line SEEPAGE PITS I I Depth Size 43 - Number SUMPS Ll Distance to nearest: Welles 3, Foundation�� Property Line 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 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: "1 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." The applicant must call for all required inspections. Complete drawing on reverse side. QD Q XSigned X Title: o� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date I U �+/ Area Pit or Grout Inspection y Date Final Inspection by b / ad L _ Date 3 �tp Additional Comments: &j d Ut'i1 Gy P—)4- Lb-/r d"_u 6 4-4-p amg y I Vi,- yP-c,,K,,4 ❑ Stk 466-678110 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Jot+--Z 4%*,Ir C Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1WJ71% If u R-C C" .e, 01- 1-0—C kJt S-d-e4 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO a EH 13-24(REV.tins) EH 14-28 • v � 9 , 1 O O