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W APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. I' ` Job Address 3`92S SIJ4-10Y A4 CityX/ Lot Size.�,S.a��Itsw"PM Owner's Namel"t9l!�C �4��P� Address JX -Sg'A i- Phone �- • ContractorAddress � w License No. Phone . TYPE..OFWELLVPUMP'--' l NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION r PUMP INSTALLATION CJ SYSTEM REPAIR ❑ OT ❑ DISTANCE TO NE : SEPTIC TANK SEWER LINES DISPOSAL F PROP. LINE I FO TION AGRICULTURE WELL OTHE LL PITS/SUMPS a " INTENDED USE TYPE OF WELL—'PROBLEM AREA CONSTRUCTIONS IFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mantec Dia. of Well avation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type 'ng Specifications f"1 Public ❑ Other ❑ Delta th of Grout a Type of Grout I I Irrigation _-.Approx, Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top,50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION € I (No septic system permitted if public sewer is CA available within 200 feet.l Installation will serve: Residence-,Y- Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: G h}y` Water table depth 7 SEPTIC TANK 51 Type/Mfg Capacity1.2QQ_Gxq No. Compartments a PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well IF7 S Foundation /CJ Property Line 1 LEACHING LINE ik No. A Length of lines -�,1�.F�� Total length/size r FILTER BED ❑ Distance to nearest: Well 0 Foundation 47 Property Line SEEPAGE PITS (kf Depth .2.S z Size 32 Number -2 SUMPS 1�1 Distance to nearest: Well ay Foundation Property Line s 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. 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 caJI for all requiredinspectionsComplete drawing on reverse side. ! Signed X // Title: 0 Ly h [.►pt= Date: X/ FOR DEPARTMENT USE ONLY p� } Application Accepted by Date 9 C Area 4��J/��jj �� 6or Grout Inspection by Date 2W Final Inspection by Date"��V Additional Comments: / "" ❑ Stk 466-6781 ❑ Lodi 1,369421 ❑ Manteca 823-7104 ❑ Tracy 8P5 63B5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24 iREV.tiKsl EH 14-26 i