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_ APPLICATION FOR PERI1 MIT SAN I; SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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" i Job Address > J Pl (31�. - , City Lot Size 1' ply li I Owner's Name I' f' 3 Address Phone Contractor .\)V• l 1 It < ILA Address . ,S-C) l A License No. t_1am�__Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTj❑ DESTRUCTION L1 PUMP INSTALLATION ❑ SYSTEM REPAIR jl❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PR09LEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing fl Domestic/Private ❑ Gravel Pack a Tracy Type of Casing ' Specifications I"1 Public Cl Other fl pelta Depth of Grout Seal Type of Grout_ I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work pone _ Well Destruction ❑ Welt Diameter Sealing Material hop 50'1 1F Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 14---REPAIR/ADDITION l I DESTRUCTION 111No septic system permitted if public sewer is �l Installation will serve: ReidenceL available within 200 feet.) Commercial Other Number of living units: Number of bedrooms 11 Character of soil to a depth of 3 feet: > >L Water table depth SEPTIC TANK CSYType/Mfg (1�LJ C jr 7, i - e-) +/� Capacit �1 PKG. TREATMENT PLT. ❑ ��- r~Q C r (t y� � Me Compartments t Method of pis osal ! Distance to nearest: Well / 0 Foundation Property Line LEACHING LINE C—No. & Length of lines Total length/size t. FILTER BED ❑ Distance to neo st: Well Foundation -S Property Line--7""— "' I SEEPAGE PITS i I Depth Size Number SUMPS N7--Distance to nearest: Well Foundation ► DISPOSAL PONDS Li ,j Property Line !) -) i I hereby certify that I have prepa►ed 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 Di§trict. Home owner or licensed agent's signature certifies the following: 111 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 taws 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 is tion laws of California.—,-., sued, I shatl employ persons subject to workman's compensa ' The applicaryt mul caul for all re red i _)tion plate drawing on reverse side. I Jf � I Sign - Title: - - kr Date: FOR DEPARTMENT USE ONLY s c Application Accepted by gg (,Date Area— V t inspection by Date �`23��/Final Inspection by 7 Inspection by r Date __ Additional Comments: r .E ❑ 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 FEF AMOUNT DUE AMOUNT REMITTED CK It INFO CASH RECEIVED BY DATE MIT'NO. + EH 13-21(REV,f w�! Q J I EH 71"28 F3!� !3- 7