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APPLICATION FOR PERMIT �' ! i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 andlor 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. t Job Address a `� City Lot Size S PM j Owner's Name f Address 11 60 �' _ 94 St ZdWE Phone ontractor Address License No, Phone j TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTE EPAIR ❑ OTHER ❑ ; DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTUR LL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA C N RUCTION SPECIFICATIONS ❑ Industria! El Open Bottom ❑ Manteca ia. of all Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of sing Specifications Fl Public ❑ Other 71 Delta Depth of G ut Seal Type of Grout I I Irrigation -Approx. Depth I I Eastern Surface Seai stalled by Repair Work Done ❑ Type of Pump P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION 1 I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence X_ Commercial_ Other Number of living units: lf__ Number of bedrooms, In Character of soil to a depth of 3 feet: 4.1Water table depth V SEPTIC TANK ❑ Type/Mfg 64 Uor, CapacitylZft No. Compartments 2— PKG. PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well � � Foundation uT� _ Property Line LEACHING LINE &f"-No. & Length of lines oZ -_ Total length/size p r FILTER BED ❑ Distance to nearest: Well Foundation _ Property Line Of SEEPAGE PITS Vr Depth o25'f Size 3t0' 1 1 _ Number 4 SUMPS Ll Distance to nearest: Well 00 -L Foundation &01 — Property Line COQ 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, a rules and regulations of the San Joaquin Local Health Diltrict. �f : 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 call all e . d inspections. Complete drawing on reverse side. Signed Title: �wm date: v FOR DEPARTMENT USE ONLY pI Application Accepted by Date A 0 Z G Area �l 2- 61 r Grout Inspection by Date ~a' Final Inspection byI~ Date Additional Comments: ❑ Stk 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 PERMIT NO. s i Est M24 IftEvt I/n 51 0