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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone Q091 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 Disttrri�ctt.. / rg �7 Job Address — -/2 fi0 � / CLs � City. Lot Size!2 2* PM Owner's NameL,., __ _� �`YYL41t— Address S,.a--� Phone Contractor Address License No3o,S?.2tPhone 3(0,PiJ�Y i 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 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public 171 Other ❑ Delta Depth of Grout Seal T t p Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done k ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feel} Installation will serve: Residence �� Commercial_ Other Number of livingunits: v , � Number of be rooms Character of soil to a_depth of 3 feet: Water table depth w f SEPTIC TANK i ❑ T .�c I r ypelMfg �� Capacity—Z-6420 No. Compartments 2— PKG. TREATMENT PLT'❑ i Method of�Diiissp�osal Distance to nearest: Well �_._ Foundation ;/ ' Property Line sy r 44 LEACHING LINE C�No. & Length of lines —?�;"s SSS 1 OTotal length/size Ir 4 FILTER BED ❑ Distance to nearest: Well Foundation� Property Line SEEPAGE PITS t I�Depthr�P"5. Size u umber SUMPS t ❑ Distance to nearest: Well 01 Foundation Property Line DISPOSAL PONDS ❑ k 0901 .ZSR f I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state la rules and regulations of the San Joaquin Local Health Diltrict. Home owner or licensed agent's signature certifies the following:3"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 callor 11 required inspections. Complete drawing on reverse side. �+ Signed XDate: +7 �_ _ Titie: eVxjeo /" r`ry! FOR DEPARTMENT USE ONLY �{ Application Accepted by QDate Area Pit or Grout Inspection by � DateW µ Final Inspection by _ T Date Additional Comments: ❑ Stk 466-6781 ID Lodi 369-3621 ❑ Manteca 823-71041 ; ] Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CCI INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT-NO. a.EH 13-211REV.1/851 �� I�vim EH 14-2a r