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APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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. THs application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 3 / V S1 � — City CC; d' Lot Size Z-8 PAVS-LrS PM :f Owner's Name ��t`t t4 0.►A d' Address rn P _ Phone 3 r� Contractor's Name CEJ License No. _ _ 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 A 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout-- El rout❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 0 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ` available within 200 feet.) Installation will serve: Residence-Z Commercial— Other Number of living units: Number of bedrooms 73— Character of soil to a depth of 3 feet: S e `-( Water table depth SEPTIC TANK ❑ Type/Mfg —c. Capacity r ZO b No. Compartments Z PKG.,TREATMENT PLT. ❑ 57 b Method of Disposal rr Distance to nearest: Wel!1�� Foundation 'Y Property Line ad LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundations Property Line 3 ._. O SEEPAGE PITS ❑ Depth Size Number SUMPS 25-v}"f1j ❑ Distance to nearest: Well"7{ 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. t- ` 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."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." t v The applica ust'c ill for all r d inspections. Complete drawing on reverse side. Signed Title: Caw ^P r Date: FOR DEPARTMENT USE ONLY I Application Accepted by Date — Area Pit or Grout Inspection by Date Final Inspection by Date ,2 Additional Comments: ❑ Stk 4664781 ❑ 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO. INFO CASH �2,IREV.,o,eal 4S` S �S 1S y�� r