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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 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. xpJob Address 1 s//•��12!,C, City•!` I�LO Lot Size PM Owner's Name %!StVCA7 —T1't/ Address 'O G Phone.�oq-gs 2� ,�ff TYRi 1' O�, C� 17f,�75 Contractor[Ty1Y ayn nmdo%sl-Address P.0 CN ACRO'P �f License�o. Phone �0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEM T ❑ DESTRUCTION 11PUMP INSTALLATION ❑ SYSTEM R AIR ❑ OTHER 1-1DISTANCE TO NEAREST: SEPTIC TANK SEWE LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICUL URE W L OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA O TRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype If Casing Specifications FI Public ❑ Other ❑ Delta Depth o rout Seal Type of Grout_ _. I I Irrigation _Approx. Depth I I Eastern Surface Sea stalled by _ Repair Work Done ❑ Type of Pump H State Work Done _ Well Destruction ❑ Well Diameter ealing Material (top 50'I Depth Filler Material (Below 501 TYPE OF SEPTICyWORIC: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 8 / available within 200 feet.) Installation will serve: Residence_ Commercial_ Other �r,C(ACk, Number of living units: _ Number of bedrooms S1 '}' Character of soil to a depth of 3 feet: v Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments j PKG. TREATMENT PILT.A �,�� Method of Dispesal Distance to nearest: Well�2= Foundation 11,.9�1...� Property Line `-L A.4, LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER.BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ 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 Dstrict. 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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 m c for al equir pections. Complete drawing on revee�rj��si�de. Signed X Title: Date: yam- / DEPARTMENT USE ONLY Application Accepted by L. .- Date Area Pit or Grout Inspection by Date Final Inspection by Date ,,, dditional Comments: J Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 8237104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17 NO. . EH 1324(REV.vx 51 ,q �a� N//( /^7 - f .-r EH 14-26 C/ 91 (/ ,/ Or 0,(