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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT j-9 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209)'466-6781 PERMIT EXPIRES 1YEAR 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 / �--� City Lot Size S PM e l7 c Owner's Name ti Z� 1 Address Z r� Phone Contractor Address .,o�� License No. Phone_ TYPE OF WELL/PUM : NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES " DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER PITS/SUMPS INTENDED USE TYPE OF LEM AREA CONSTRU PECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ' Type of Ca'sin`g. i Specifications F] Public ❑ Other to _bepih`of Grout Seal .w. Type of Grout I I Irrigation _.-Approx. D I I Eastern . Surface Seal Installed by _ Repair Work Done O Type o mp H.P. State Work Done_ Well Destruction ❑ ell Diameter 1 Se`alirig Material (top 50'1 Depth Filler Material (Below 501 . TYPE OF SEPTIC WORK: NEW INSTALLATION I I".REPAIR'/ADDITION l I DESTRUCTIO I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ` Number of living units: Number of bedrooms - Character of soil to a depth of 3 feet: I fi Water table depth SEPTIC TANK ❑ Type/Mfg Capacity t No. Compartments 6 PKG. TREATMENT PLT.^❑ I Method of Disposal Distance to nearest: f Well Foundation Property,Line s . LEACHING LINE ❑ No. & Length of lines 4" Total length/size FILTER BED ❑ Distance to nearest: c Well Foundation Property Line - E SEEPAGE PITS I I Depth Size _ Number t SUMPS - ❑ Distance to nearest: i 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. — f- 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 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 mus call for all req 'red inspections. Complete drawing on reverse side. Signed X Title: V�k.-,4 V Date: FOR DEPARTMENT USE ONLY l Application Accepted by _~ Date o" _ Area C Pit or Grout Inspection by / Date Final Inspection by Date Additional Comments: I ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. +.EH13-241REV.i/Hsl _ G �+! EH 14-2a 6i