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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) 4 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. I Job Address ///,d / Cit S Lot Size �� f/� 2 ,PM � y Owner's Name T� Address / C&ILAi A7�I+W VO-`�n 9.6210 Phone 931—Z�/ 2 Contractor Address 6W247, AAs. License No. �Z9'22-,6 Phone_ TYPE OF WELL/PUMP:( NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR.O© OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTUREYVEI_L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARI=A CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mant6i5a� Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing — Specifications C1 Public CI Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation pprox`Depth I I Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done Well Oestruc- ❑ Weil Diameter Sealing Material (top 50') { Depth ~` Filler Material (Below 501 6' 11 TYPE OF SEPTIC WORK: NEW INSTALLATidw.1 REPAIR/ADDITION-1,1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) E Installation will serve: Residence-2—y' Commercial_ Other Number of living units: J_ Number of bedrooms " I Character of soil to a depth of 3 feet:j Water table depth d00 I SEPTIC TANK Pr Type/Mfg Capacity__/419�_ No. Compartments r k PKG. TREATMENT PLT. ❑ I I Method of Disposal Distance to nearest: Well y Foundation" /D Property Line LEACHING LINE fjLY No. & Length of lines g Total length/size 1140 2 FILTER BED ❑ Distance to nearest: Well 50 / Foundation /O � Property Line .5� r SEEPAGE PITS W( Depth .4 Size' �x _ Number SUMPS L1 Distance to nearest: Well IDD�— Foundation /E] Property Line S DISPOSAL PONOS ❑ r 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 Dt%trict. 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."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 all for all required inspections. Complete drawing on reverse side. Signed X 49 r .Ccs Title: Date: FOR DEPARTMENT.USE ONLY Application Accepted by r Data �a Area Pit or Grout Inspection by Date "f Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1323-7104 ❑ Tracy 835-6385 Applicant - Return all copieNto: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 v FEE t INFO AMOUNT DUE r.: AMOUNT REMITTED CASH RECEIVED BY CK 4 DATE PERMIT'NO. +.EH 13-24(REV.1/n 51 �{ EH 14-28 b