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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 i Local Health District. z Job Address / S Z902 City Srecl<l OYLot Size PM l Owner's Name � � �� Address IVIJ 4-'C70-42 elCe4FA Phone e 7a " 4/-Z-9 Contractor thSox�a Address 3PRO N Cvr sa WALicense No. Phone_ +:G" a1 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 I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I 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` 11 Public F Other 171 Delta Depth of Grout Seal Type of Grout I I'Irrigation —,.Approx. Depth i I Eastern Surface Seal installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 ` TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDiTIONW DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) i Installation will serve: Residence Commercial____ Other Number of living units: Number of bedrooms ._ j Character of soil to a depth of 3 feet-' Water table depth SEPTIC TANK Type/Mfg `PAPenrsM fisous Capacity 1.200 41 . No. Compartments r PKG. TREATMENT PLT. ❑ _ ' Method of Disposal Distance to nearest. ' :!Well Foundation 4Property Line .F 4 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' � 1 SEEPAGE PITS I I Depth Size Number SUMPS L] 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. 1 Home owne-r or licensed agent's sigriature 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 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 must call for ail required inspections. Complete drawing on reverse side. Signed XKk, � Title: s t Date: -7-1b 'g FOR DEPARTMENT';USB ONLY } Application Accepted by _ Date ? V Area ! Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,-CA 95201- ti FEE INFO AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY !DATE PERMIT7NO. +.EH 13-24iREV.I/n5) i A •�� •� X59 EH 14-2e