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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephohe (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. Cp Job Address �0� -' / i City�f' 6 Lot Sze PM Owner's Name )V,r ! /mm-Lt, Address Phone q V24 b q-3 .;Contractor 'pts--� Addres.s,3I0•C`A_`_J+0" License N,. Phone TYPE OF WELL/PUMP: 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 PR08LEM AREA CONSTRUCTION SPECIFICATIONS Y ❑ Industrial © Open Bottom ❑ Manteca.. "' :Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications €1 Public (=1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation f — Approx. Depth t I Eastern Surface S6al1Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Weil Diameter Sealing Material (top 50') ( *� Depth Filler Material (Below 50') �✓V TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAtWADDITION l ESTRUCTION I I (No septic system permitted if public sewer is 3 ' available within 200 feet.) a j Installation will serve: Residence_L Commercial_ Other Number of living units: _L_ Number'of bedrooms Character of soil to a depth of 3 feet: : - Water table depth SEPTIC TANK N--rpe/Mfg C—ir)WC1116-t& t Capacity f A00 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well X50 Foundation Property Line LEACHING LINE Lits. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well :Foundation Property Line a SEEPAGE PITS 1 I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property fine DISPOSAL PONDS ❑ 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. i Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shalt 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 la alifor ia." The applica t mu c II for a req 'red i pecti n o ate drawing on reverse si e. Sign Title: _LiTA Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area p- Pit or Grout Inspection by 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 AMO//U''NN�T DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. +.EH113-2 rREY. al E4-ZB CCC tiAS) -7U H oly -� i V t