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'- '-`] APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. e Job Address '2 464,17'k Q City S Lot Size PM Owner's Name 48 4l ( 'a Address �+�� e Phone 64' 6 p 71 Contractor_ ..- Address - --License No. - .�.� Phone � r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE5DISPOSAL FLD. PRO --- FOUNDATION AGRICULTURE-WELL OTHER WE PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT! IFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑10ther el Pack ) ❑Trac Type.:of Casing ^"��""�� Specifications F]I Public ❑ '�/ Delta Depth of Grout Seal Type..of Grout _. V r I I Irrigation p epth ,"I I Eastern Surface Seal Installed by r _ Repair Work Done ❑ Tgpe of Pump I H.P. State•Work Done Well Destruction ❑ Well Diameter Sealing Materiai'itop 50'I Depth FillerMaterial (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION DESTRUCTION'[ I (No septic system permitted if public sewer is ` available within 200 feet.) Installation will serve: Reside6ce__X C mo mercial k-7Other Number of living units: / Number of-bedrooms 3 Character of soil to a depth=of 3 feet: aF' P Water table depth.. �� SEPTIC TANK Type/Mfg 4� L Capacity 120 No. Compartments `l PKG. TREATMENT PLT. ❑ ,,/ ,/ Method of Disposal Distance to nearest: Well e® e I Foundation o Property Line s LEACHING LINE (! No. & Length of lines VS Total length/size FILTER BED ❑ Distance to nearest: Wel! Foundation G 11Property Line A_SEEPAGE PITS Depth ,s Size; Number SUMPS ❑ Distance to nearest: . Well Foundation- /Q - Property-Line J, DISPOSAL PONDS ; ❑ ' x I hereby certify that I have prepared this application and that the work will be done in a cordance with San Joaquin county ordinances, state laws, and rules and regulations of tWSan Joaquin Local Health pilthct. Y' ' Home owner or licensed agent's signature certifies the following: "I certify that in therform ante 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."Contiactor s hiring or sub-contracting signature certifies the following<�l-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 m call for all required insction .Complete-drawing-on"reverse-side: *-��--a-' tee' c Signed X Title: Date: OR DEPARTMENT USE ONLY Application Accepted by '. Date `s Area i, � � � Pit or Grout Inspection by Date Final Inspection by °'��L1 Date Additional Comments: ❑ 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 96201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE OyPERMIT NO. +.EH 13-24)REV.t i w 51 -70 �• 3 "�" (� 0^ 4/11/EH 10-28 }