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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (2091 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 District. Job Address 4-,2 3 City Size PM Owner's Name Al SLI L;4:^ k5/„Yr'15 1 Add. 4 22ta Y-'-I,0 SG 5 Phone - Contractor's Name & 4�'� License No. '56041 Phone a o�� 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 f Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private C Gravel Pack ❑ Tracy Type of Casing Specifications ` Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout T Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction _. Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 14 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is (1 available within 200 feet.) Installation will serve: Residence_ Commercial_ Other feeJ71 k C Number of living units: -j�Z_ Number of bedrooms <2 r j Character of soil to a depth of 3 feet: F, lL Water table depth f SEPTIC TANK ❑ Type/Mfg Pr'Le.z_s" L'15)p%C CapacityL No. Compartments PKG. TREATMENT PLT. ❑ 11__ Method of Disposal Distance to nearest: Well l so 4- Foundation If 0 Property Line to LEACHING LINE �j No. & Length of lines Y'Si^P - 4,75 ` Total length/size ` FILTER BED Distance to nearest: Well /50 Foundation In ' Property Line It SEEPAGE PITS X Depth 5k Size '33 Number I)Y^ e-- SUMPS SUMPS -- Distance to nearest: Weft Foundation Property Line 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, 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: "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 for all rwoRg7ed rPapections. Complete drawing on reverse side. Signed n/'�7. /�� Tile: frt 7 Date: - Y ` ,,IT FOR DEPARTMENT USE ION / 7— Application Accepted by �� nt't I ` ' Z r-, ✓ Pit or Grout Inspection by Date LW Final Inspection by I Z Date / /y Additional Comments: i11 b/lY JY�_y S'-;10 -= Y"'_�'i.L(utirt i o , C Stk 466.6781 ❑ Lodi 368JB21 ❑1 Manteca 8ZI-7104 C Tracy 836-63135 Applicant- Ratum all copier'to: Environmental Heatth Permit/Services 1601 E. Hazelton Ave.. P.O. Box 2009. Stk., CA 95201 INE AMOUNT DUE AMOUNT REMITTED CA6N RECEIVED 6r' DATE ryJPERMIT/NO. . EM t&2{(REV. 10/1131 YJ /3 / V� V 1 I EH tom �