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n � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hefeby 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. C t Z/p �g_ Job Address IS- 1 2 J7 ' A- Paf`'��-- co k1i City �� Z Or1_CCAbt Size -c-1" -erPM Owner's Name,J Lsu_s: A P A m egAdpress t © 9 V 'f- Phone 0 , Contractor 1 Ad License No. Phone TYPE OF WELL/PUMP: NEW V , : WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTAL_`,' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDAT U TURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE,'µ P A CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Q; "y Type of Casing Specifications I`] Public a Depth of Grout Seal Type of Grout I I Irrigation mak. }-` a Eastern Surface Seal Installed by _ Repair Work Done ❑ fmunW H.P. State Work Done _ Well Destruction ❑ iameter Sealing Material (top 50') th Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION f REPAIR/ADDITION I ) DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence le Commercial_ ther -011"Number of living units: A. Number of bedrooms � 1 J Character of soil to a depth of 3 feet: N ` L-r / r'"1 Water table depth SEPTIC TANK [Type/Mfg �' L 9 PI, 0"'e-( 4pacity L� No. Compartments PKG. TREATMENT PLT. ❑ f - i Method of Disp$sal j. 191n'f' ••�� ►Distance to nearest: Well 7 Foundation 3 Property Line LEACHING LINE W No. & Length of lines �,r� Total length/size 2—® FILTER BED El Distance to nearest: Well o® Foundation h Property Line f 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. a 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 followin "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 Califo The applicant st call for all qu'a inspecti . Complete drawing on,le side. Signed X Title: �JDate: 7/h FOR DEPARTMENT USE ONLY Applica ' n Accepted by Date Area Pit or Grout Inspection by Date /Final Inspection by Date Additional Comments: �7if !f/ ,d�►:' �!Y'� �° ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835- Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0. Bo 2409, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. + EH t14-26 3-24(REV.,,o EH I� l v� `�.�(� Ot"O �'/'7-W10 /*�� JI��2t ( y J 6 /