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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 Local Health District. �I ` - a Job Address 39L3s S,0AWY City / Lot Size an.) '.x� �•j,�M Owner's Name Address -- 7•�•s —s�//LIf;y �ll�, Phone - Contractor �J "' Address License No. Phone_ TYPE_OF WELL,/PUMP---4 $' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OT ❑ DISTANCE TO NE : SEPTIC TANK SEWER LINES DISPOSAL F PROP. LINE ``'" F FO TION AGRICULTURE WELL OTHE LL PITS/SUMPS INTENDED USE TYPE OF WELL BLEM AREA CONSTRUCTIONS IFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mantec Dia. of Well ovation Dia. of Well Casing ❑ Domestic/Private © Gravel Pack ❑ Tracy _ Type ng Specifications I'1 Public Cl Other E-] Delta th of Grout Se Type of Grout I Irrigation -Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump P. State Work Done _ yJ Well Destruction ❑ Well Diameter Sealing Material (top,50') Depth Filler Material iBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is (A available within 200 feet.) Installation will serve: Residence-,Y— Commercial_ Other r Number of living units: i Number of bedrooms Character of soil to a depth of 3 feet: C `A.4 Water table depth 7 SEPTIC TANK IR Type/Mfg f ah,et-LYl'e_ Capacity 1.21110 6/ No. Compartments — PKG. TREATMENT PLT. ❑ Method of Disposal 1 Distance to nearest: Well 17 s Foundation /U Property Line 1 LEACHING LINE No. & Length of lines ^2�C � Total length/size 220 /X 2z4,2WE FILTER BED ❑ Distance to nearest: Well/sZ n Foundation Property Line--- SEEPAGE PITS 1f[1 Depth s_" Size Number I SUMPS ❑ Distance to nearest: Well 4ZV Foundation��.� Property Line -.S 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 Di"strict. 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„1he 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 Al for all required inspections Complete drawing on reverse side. I Signed X__ Title: 42 LLAt 0th Date: FOR DEPARTMENT USE ONLY p� Application Accepted by _ Date ~ l Area jsior Grout Inspection byDate TJ,..rjW Final Inspection by Date Additional Comments: 1` I ❑ Silk 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 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. +.EH13-24iREV. 51 - �f,J. EH 14-26 1 c y P