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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1.601 E. HAZEL T ON 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. Job Address City f'a't Lot Size,aXAP_4) PM ,rOwner-s,Nam ' F AddressQ9 Phone Contract `'A , I t Address �c W / r License No. 9 � Phon ( " .5�� � TYPE OF,WELZ/PUKAP7 t. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Q ^; ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of lasing' - Specifications r1 Public ❑ Other Cl Delta Depth of Grout-Seal; Type of Grout ' _X_ I I Irrigation _.-Approx. Depth Surface Seal Installed by _ Repair.-Work Done ❑ Type of Pump; H.P, State Work Done I Wert Destrtfction Sealing — — z l l ''7, Depth � filler Material IBalow 501 (T y TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 (REPAIR ADDITION I DESTflUC710N I 1 iNo septic system permitted if public sewer is `T available within 200 feet.) Installation will serve: Residence! Commercial Other i Number of living units: _L_ Number ; edro ms �� t Q '70 Character of soil to a depth of 31eet:- - ' ' °r Water tablerdepth SEPTIC TANK ❑. Type/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ F ,/F +T`- �'-'Y Method of Disposal 1! 1 Distance to nearest:; i Well Foundation Property Line LEACHING LINE No. & Length of lines ' Total length/size -i t —_ �� P y --.-�:_: FILTER BED 1:1 Distance to..nearest: Foundation Property earest: Well D ro Line SEEPAGE PITS W Depth Size 33 Number SUMPS LI Distance to nearest: _ Well/DO ' I foundation�� Property Line DISPOSAL PONDS ❑ { ✓ K 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 t&becoma 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." /9 , The applicant call for quer d inspections. Complete drawing on rever a a. a( I Signed X Title: '- - z Date. `f 0 FOR. EPARTMENT USE ONLY Application Accepted b Date Area CM/t,{c`7r Grout lnspectian bye//� Date Inspection by ate A Additional Comments: ll�in.l ee 'LJ_Stk.-466-6781_ _— ❑-Lodi x369-3621.,,- _.❑_-Manteca._.823-7104 .„- ❑ Tracy 835-6385 - I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I L FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH i C + EH 13-24 MEV.11 H s1 ` Z� ti C7 ��{i✓1 EH t4-28