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APPLICATION FOR PERMIT : SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED &_ ./ { tiplete in Triplicate) J Ep 21 799(3 Application is hereby made to the San Joaquin Local Health Dist iict 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. Z&_P_4$—1'y PRIPONMENTAL HEALTH 1Zs�z_V—cs�� PERMITISERNACES Job Address 2-f-b-q City Lot Size PM ,� �,roo Ar,�e.-.c�.e .G,.e L��r✓e Owner's Name a � � Address qs ss Phone Contractor �e,A ��n� Address 2�esr /xi�e License No. '5f7-7-66 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP DISTANCE TO NEAREST: SEPTIC TANK SEWER ❑ SEWER LINESYSTEM REPAIR OTHER DISPOSAL Ftp, ROPSN�r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS (J\ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO I ❑ Industrial ❑ Open Bottorn ❑ Manteca -Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing seeifieetiensy ❑ Public ❑ Other ❑ Delta Depth of Grout Seal //// Tpp i I Irrigation --Approx. Depth I l Eastern Surface Seal Installed by t`' 1-- Repair Work Done ❑ Type of Pump H.P. State Work Done - Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l 1 DESTRUCTION l I (No septic system permitted if public sewer is # available within 200 feet.) I Installation will serve: Residence_ Commercial_ Other r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK LI 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 l I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 s ll squired inspections. Complete drawing on re rse ids. ` Signed X Title: Date: - 3 DARTMENT USE O Y Application Accepted byAj��Z�FOR Date 6� U Area Pit or Grout Inspection by Date Final Inspection by Date l Additional Comments: # Ll 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 `` I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO CASH DATE PERMIT'NO. ♦ EH 13.24(REV.)IK5) 1- Q EH 14-26 �I.L t O