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cl- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 \, .�� 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. Job Address 119S_3 v 99w- City ©e Lot Size PM Owner's Name !\/ / r \ Address l v ''7 0-7o, one `�- ContractorZ'� Address License No. Phone PE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTAL TION ❑ 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 OBLEM CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pa ❑ Tr y Type of Casing Specifications F1 Public ❑ Other F1 Delt Depth of Grout Seal Type of Grout _ I I Irrigation _.Approx. Depth t I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H. State Work Done_ Well Destruction ❑ Well Diameter Sealing aterial (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms L(� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ---------------- 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 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." The applicant t call for all required inspect' ns. Complete drawing on reverse side. Signed X Title: /�wcC.L /l , Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Z Area Q-�7 Pit or Grout Inspection by DFinal Inspect - Date ��G ). A ditional Comments: l(, f Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 plicant- Return all copies to: Environmental 6p Health Permit/ rvices 1c EoHazeltAve., P.O. Box 2009, Stk., CA 95201 — t® .� INFO FEE AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY ` DATE PERMIT NO. r EH 124(REV.t i x 5) EH 14-4-28 111 �tJV