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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 ' fComplete 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 t / Job Address Z/ff City Lot Size �PM Owner's Name � �n '� Address �� 7L , 4 Phone 2 f _ G Contract Z,2) At Address ��- ✓ 7 '�� License No. �z Z. Phone �4 -Ild ` f TYPE OF WELL/PUMP: NEW WELL CI WELL REPLACEMENT 0 DESTRUCTION 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ '` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE *ter FOUNDATION t t AGRICULTURE WELL OTHER PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION WWCTFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of xcavation Dia. of Well Casing ❑ Domestic/Private 0 Gravel Pack 0 Tracy of Casing Specifications 1'] Public ❑ Other n D 'a Depth of Grout Seal Type of Grout` I I Irrigation _.Approx. Depth I ern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump, H.P. State Work Done Well Destruction ❑ Well D' er Sealing Material Itop 501 pth Fillpr Material !Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION 11 4ZLIRIADDITION l J. DE_ST_RUCTION 1_l INo septic system permitted if public sewer is available within 200 feet.) ; .Installation will serve: Residence_y_ Commercial— Other1 Number of living units: ___/__ Number of qedrooms Character of soil to a depth of 3 feet: °I Water table depth ' f � i SEPTIC TANK �'Pype/Mfg ` iidrtLr` ' . Capacity- ' ,[A&gINo. Compartments .2 PKG. TREATMENT PLT. ED ! Method of Disposal " Distance to nearest: Well LO 4t Foundation Property Line LEACHING LINE No. & Length of lines Total length/sl e FINER BED ❑ Distance to nearest: Well—" � Foundation lib Property Line 9 SEEPAGE PITS 1 1 Depth Size, �� g Number F I SUMPS I11•?" Distance to nearest: Well >3 66 � c Foundation 1 40 Property Line DISPOSAL PONDS ❑ I hereby certify that Fhave prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and h rules and regulations of the San Joaquin Local Health Ds?trict. - Home owner or licensed agent's signature certifies the followin � g g g: '9 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 subcontracting 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." t w The applicantmust c for all required i ctions. Complete drawing on reverse side. a Signed X Title: Date: FOR DEPARTAAENT USI~ QNLY Application Accepted by 0 � � Date I.-2 Y�-17 r,)——Area —r'3 � c� E Pit or Grout Inspection by Date Final Inspection by ��J Date Additional Comments: ❑ Stk 466-6781 0 Lodi 369-3621 t 0 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 r FEE CK INFO `AMOUNT DUE AM}OUNlT1 REMITTED �i� CAr7SGtH RECEIVED BY D!A'TE[�l PERMIT'ND. + EW 13-241REV.r/nbf 1+ ` O l f�ry Vv'n 1' �2 f'l'�'-[V x'0_27 EW t!-2t1 `�-O"!