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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �I 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I� do I PERMIT EXPIRES 1'YEAR FROM DATE ISSUED , hgj, (Complete in Triplicate) Application is-hereby made to thia 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. " Job Address City Lot Size PM Owner's Name Ona Address / Phone ji Contrac - AddressC>Q- 'd 442 License No. a'hone �� 7Q✓ TYPE OF ELL/ I� NEW WEL ❑ WELL R ACEMENT DESTRUCTION ❑ PUMP INSTALLATION STEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWE INES DISPOSAL FLD. PROP. LINE FOUNDATION A CULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROB M AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom LJant a Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private °❑ Gravel Pack Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout —. I i Irrigation W .11.Approx. Dept I Eastern Surface Seal Installed by f Repair Work Done ❑ Type of Pump ` ' H..P., State Work Done Well Destruction ❑ Weil Diameter Sealing Material (top-501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION 6,111110 septic system permitted if public sewer is available within 200 feet.) I ..Installation will serve: Residence— Commercial_ Other' ` Number of living units: 'F Number of bedrooms Character of soil to a depth of 3 feet: 6 I Water table depth ` SEPTIC TANK Cie/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ II: Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ f o. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number r SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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. I ' Home owner or licensed agent"s signature certifies the following: "I certify that in the performance of the work fot 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 certifythat in the performance of the work for which this permit is issued, t shall employ persons subject to workman's compensa- tion laws of California." The applicant mu t call for ail PcIVred inspections. Complete drawing on ryerseAkde. Signed b Title: Date: Co'L 97 PARTMENT USE ONLY1-7 Application Accepted by A wA ��OR .9Ah,/�O.iv�+t/�_-— Date �� `� Area Pit or Grout Inspection by{��I! Date Fr al Inspection b Date Additional Comments: — - - ❑ Stk 466-6781 ❑ Lodi 360-3621 ❑ 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 it FEE AMOUNT DUE AMOUNT REMITTED CK 49 ,RECEIVED BY DATE PERMIT'NO. INFO CASH r go + EH 13-24 ISM r/)15) 46 f 1;S EH 14.29 II r