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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES`l 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. I ll Z �J {( Job Address - City �` Lot Size PM I\ — /fit- 7l moi ; ` y.. Owner's Name l f d� Address ! �i��(` i/�• � {� 1�, ff�Phone �[ /� 1 Contractor�f7LLf'/y' � ST�tf4PJl bdress ` b �'�l��jS J License No. ^� l �I�Phone Z ~ - TYPE OF WELL/PUMP: NEW WELL ❑ LL REPLACEME ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ YSTEM REP IR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE ELL _ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONS UCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. f ell Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T e of C sing Specifications i'1 Public n Other (-1 Delta epth of G ut Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal nstalled by Repair Work Done ❑ Type of Pump /H.P. State Work Done_ Well Destruction ❑ Well Diameter _ g Material (top 50')Depth Material (Below 501 j TYPE OF SEPTIC WORK: NEW INSTALLATION RE AIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other t � f Number of living units: _J_ Number of bedroom — Character of soil to a depth of 3 feet: —-_ L 46'i & Water table depth SEPTIC TANK ❑ Type/Mfg Cr Il G7f;f,'T1' Capacity 49 - % t No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal LEACH Distance to nearest: Well % �i'Ff�oundation 1 y`l1`r Property Line LEACHING LINE ❑ No. & Length of lin �� Total length/size FILTER BED ❑ Distance to nearest: Well Foundation 100 a Property Line cC ; SEEPAGE PITS l 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 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 required inspections. Complete drawing on reverse side. Signed XBs,'l�ifU'l �' �J Title: Date: , 6 FOR � ARTMENT USE ONLY Application Accepted byL� x ' ` �*► �"��`� �� Date d� Area Pit or Grout Inspection by Date Final Inspection by 9_4Date 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, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO EH 1241REV.i'x51 CC',�. r-,� EH 14 28 C