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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Lf-�j�� 1601 E. HAZE i ON AVE., STOCKTON, CA \� Telephone (209) 466-6781 /,7 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.` L Job Address �/ �� City ` Lot Size 49 X 13()PM Owner's Name Loo A-1.461.4 S t-1 Address S /f C4 e4a- Phone �1 S� U r Contractor Address License No. Phone_ TYPE OF WE NEW WELL ❑ WELL REPLACEMENT ❑ DEST ION ❑ NSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TA SEWER LINES OSAL FLD. PROP. LINE FOUNDATION GRICULTURE WE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A> CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom eca Dia. Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pa ❑ Tracy Type of Ca Specifications F] Public ❑ 0 r ❑ Delta Depth of Grout Sea �Wo Type of Grout __ I I Irrigation Approx. Depth l I Eastern Surface Seal Installed _ Repair Work Done ❑ Type of Pump H.P. _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION NrWo septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms 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 ❑ 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: "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 mu call f all required inspections. Complete drawing on reverse side. Signed X �/ �-e�L� 2 Title: J Date: FOR DEPARTMENT USE ONLY Application Accepted by Date / Area Pit or Grout Inspection Date Final Inspection by 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 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.1/85) EH 14-26