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APPLICATION FOR PERMIT 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) FILE, COPY ':�— Application is he+eby 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. j Job Address S49 400 City sZLe_k- Lot Size rsi` �X 96/,/7 f'M Owner's Name ow"i C C Address �V+Xs -s(A'A'Y R1 __ Phone7- Contractor �.-I Address License No. Phone ! TYPE OF'WELL./PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OT ❑ . DISTANCE TO NE ,-_SEPTIC TANK SEWER LINES DISPOSAL F PROP. LINE FO TION AGRICULTURE WELL OTHE LL PITS/SUMPS INTENDED USE TYPE OF WELL BLEM AREA CONSTRUCTIONS IFIGATIONS ❑ Industrial D Open Bottom ❑ Mantec Dia. of Well. . ovation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type ng Specifications j M Public 1-1 Other n Delta th of Grout a Type of Grout _ I I Irrigation --Approx. Depth I ) Eastern Surface Seal Installed b�y Repair Work Done ❑ Type of Pump P. ork Done Well Destruction ❑ Well Diameter Sealing Material (top,501 r 4 Depth Filler Material (Below 501 ' r�AR TYPE OF SEPTIC WORK: NEW INSTALIJAMON REPAIR/ADDITION 11 DESTRUCTION I I (No septic system permitted if public sewer is �` available within 200 feet.) Installation will serve: Residence_Y_ Commercial_ Other Number of living units: .'.. "." Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 7 SEPTIC TANK CA Type/Mfg f/1 dAC_I• _hL Capacity /..2 0-0 Gia! No. Compartments J PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well 1.2 X--- Foundation L10 Property.Line y Z/ LEACHING LINE 10 No. & Length of lines X �� Total length/size D z FILTER BED ❑ Distance to nearest: Weil 1..7 0 Foundation w Property Line SEEPAGE PITS lief Depth .2.5 • Size � Number - SUMPS Ll Distance to nearest: Well Foundation Property Line S DISPOSAL PONDS ❑ 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."Contractors hiring or sub-contracting signature certifies the following:"I certify tha_t.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 ca I for all required inspections Complete drawing on reverse side. Signed X Title: w ti toDate: '1/ 1f Q FOR DEPARTMENT USE ONLY p� } Application Accepted by Date ` Area ` ��1or Grout Inspection by Date�lj Final Inspection by Date j Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 1324 IREV. /n sf EH 14,28