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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT COPY 1601 E. HAZELiON 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address Zag_.-,75— =s /ggif7/2� L'��Z City,.r fiSriu"I_ Lot Size r -IS PM Owner's Nama 4Address Phon� Contractor t-13 Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0.Industrial CI Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic I Private ❑ Gravel Pack Q Tracy Type of Casing Specifications M Public Cl Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Wail Diameter Sealing Material (top 50') Depth- Filler Material (Below 50'1 lN) TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is 1� � � available within 20D feet.) Installation will serve: Residence_ Commercial Y other Number of living units: ro:� Number of bedrooms ;- Character of soil to a depth of 3 feet: S&In �T L--06rin Water table depth SEPTIC TANK LTJ' Type/Mfg e9�G +�o.�crc��- Capacity Mp o� No. Compartments PKG. TREATMENT PLT.❑ of I&q-0 Method of Dispoyl Ll n 4— Distance to nearest: Well�` Foundation 21 Property Line 41400 LEACHING LINE L�No. & Length of lines —1 !2 O7 0 7 tel length/size a L ''9 t Qr �— _ o FILTER BED ID Distance to nearest: Well�� Foundation 2 +� Property Line 4 G SEEPAGE PITS I ) Depth Size Number SUMPS Ll Distance to nearest: Well 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 Diktrict. 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 shalt 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 compansa- tion laws of California." Theapplicant for all r pections. Complete drawing on reverse side. Signed Title: Date: R DEPARTMENT USE ONLY Application Accepted by /04/ +Y""� Date Area Pit or Grout Inspection by Z Fi I Inspection by Date Z Additional Comments: rf ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca -7104 ❑Tracy 835-6385 Applicant- Return all copies to: Environmental Health Parmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. INFO ♦,.EH 1341{HEY.t/N ai EH t�- �'� /c`, r�Q�3 ��1.14-A �_j