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�.w 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) 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. p / Job Address City Lot Size A Q At , PM Owner's Name• W1 ��'— gf- I(/�Address S10 S `eu.__/./ /�+� Phone ` Contractor CAA& 4 Address --Cfdr- ZJ.,1a.1b1 License No. Phone — 1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA9EMENT ❑ DESTRUCTION ❑ PUMP;INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _ E TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PR E OUNDATION AGRICULTURE WELL OTHER WE PITS/SUMPS INTENDED USE TYPE OF WEL M AREA CONSTRU CIFICATIONS O Industrial ❑ Opep Bottom ❑ Manteca 1 Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Type of Casing Specifications FI Public ❑ Other Cl Delta Depth of Grout Seal T pe of Grout_ _ I I Irrigation pprox. Depth I 1 Eastern Surface Seal Installed by Repair Work ❑ Type of Pump H.P. State Work Done Wel estruction ❑ Well Diameter Sealing Material (top 50'1 ('n Depth Filler Material (Below 501 v , TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is Q) - /rte L available within 200 feet.) t /y Installation will serve: Residence(Commercial Other_.. ION STvo 6 Number of living units: sZ5 Number of bedrooLrys--� . Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK X_ T Mfg Qti.S-� - �� Capacity /2a C11 No. Compartments l PKG. TREATMENT PLT Method of Disposal Distance to nearest: Y11O11 —Z-0-- Foundation Property Line (C LEACHING LINE No. & Length of lines Total length/size d 1 FILTER BED ❑ Distance to nearest: Well 7J-Cl, Foundation Property Line id f77 C SEEPAGE PITS 11 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line -- DISPOSAL PONDS - ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, nd rules and regulations of the San Joaquin Local Health D13trict. Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the workfor 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 fqrr all required inspections. Complete drawing on reverse side. Signed X 159i-.Title: Date: e< _1/— y19 FOR DEPARTMENT USE ONLY Application Accepted by (J-) Date Area Pit or Grout Inspection by Date Final Inspection by Oate Additional Comments: It ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 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 C/IK RECEIVED BY DATE�,/` PERMIT'N`O. . EH I}2x IREV.1/x51 6 - / �� / -/�i[r- �� EH 14M ✓ l0 ll