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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) i 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. [� ? �J L.l j �] Job Address _11!rJ to. C� /`T ��11 / City t Lot Size _CSS /4G PM Owner's Name i�OA/Y� 1C.t 1�6J�T Address I l 7 3 0 Cg` e / 2- Phone r.�✓ /��A Contractors Address T � S J OGi[I{]6, License No. ��;Z Phone36F9533 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 if FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �} INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public F) Other 11 Delta Depth of Grout Seal Type of Grout— as rout l ' I I Irrigation ______Approx.TDepth i I Eastern Surface Seal'lnstalled by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION € I REPAIR/ADDITION I DESTRUCTION I I (No septic system permitted if public sewer is 4 available within 200 feet.( \ Installation will serve: Residence' 100`� Commercial_ Other Number of living units: —I— Number edrooms e2 } Character of soil to a depth of 3 feet: %_6pgM �� ,,�' Water table depth SEPTIC TANK f� Type/Mfg ak T -149 VAC Capacity/[0 No. Compartments Z PKG, TREATMENT PLT. ❑ t Method of Disposal 0,01 Distance to nearest: Well Foundation Property Line LEACHING LINE �No. & Length of lines �r Total length/size - a FILTER SED F41' Distance to nearest: Well—L r Foundation ..36' Property Line �® SEEPAGE PITS IM"_Depth c,ZS Size 36 Number / f SUMPS Ll Distance to nearest: Weil Foundation t& Property Line DISPOSAL'(PONDS ❑ I hereby certify that l 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: "1 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 Califomia." *% E The applicant must call fo all r9quired inspections. Complete drawing on"reverse side. �+�] Signed X .., .. F Title�_tG��M�f Cd ��J��Q / Date: FOR DEPARTMENT,USE ONLY Application Accepted by y� date /9-TArea Pit or Grout Inspection by Date rASIFinal Inspection by Date Additional Comments: ❑ 5tk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ,Applicant - Return all c pies 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 PERMIT'NO. a ��r�/ l + EH 13-24IREV.1i95) U 1o'"`�'/ EH 14-26 r v {1