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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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. / Job Address f J V INV ' City Lot Size 1 4'zey PM r"'\" Owner's Name _ L//n Address 11qgdWl-i 14 L;4,1 Phone 7 741 /►contractor 'E`"F Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE ENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTE EPAIR O OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTUR LL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C N RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of sing Specifications .� ("1 Public ❑ Other ❑ Delta Depth of G ut Seal Type of Grout _ I I Irrigation —Approx. Depth I I Eastern Surface Seal stalled by _ Repair Work Done ❑ Type of Pump P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) .� Installation will serve: Residence_X_ Commercial_ Other fn Number of living units: I Number of bedrooms_.-3 Character of soil to a depth of 3 feet: CJ4.v Water table depth V SEPTIC TANK ❑ Type/Mfg Capacity /fit)fP No. Compartments 2— PKG. PKG. TREATMENT PLT. ❑ Method of Disposal /Distance to nearest: Well �fi Foundation �0 Property Line /OQ LEACHING LINE Iter No. & Length of lines I Z3s+ Total length/size r r FILTER BED ❑ Distance to nearest: Well Foundation Property Line ,r SEEPAGE PITS Depth o2'�r Size 3 W Number Q SUMPS Ll Distance to nearest: Well 100 4- Foundation &0/ 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, a 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 all re ired inspections. Complete drawing on reverse side. B Signed X Title: ��r1 �hC' Date: / \ FOR DEPARTMENT USE ONLY a / Application Accepted by Date �' Z Ct Area it r Grout Inspection by Date 2� - !!� Final Inspection by'E / Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CASH �..:�`fH 13=24[RE .�.,. - > >.. ,. .r..... ,.. �. C crr d r EH 14-26 , Q