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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 1 YEAR FROM DATE ISSUED (Complete in Triplicate) tv... Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install tfie 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: { /yam n / ' Lot Size PM �O3 Z Z L/ /� city Job Address �r ; Address 7' , — Phone Owner's Name _ � r-� OOr�� /T� �� Tf ��2�' 0�� .—Phone.. � C.antractor d� Address, ��' License No.. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r SEWER LINES �— DISPOSAL FLD. PROP. LINE DISTANCE T EAREST: SEPTIC TANK � U FOUNDATION i AGRICULTURE WELL OTHER WELL I PITS/SUMPS I CONSTRUCTION SPECIFICATIONS1 INTENDED USE TYPE OF i pia. of ell" 0,1111 ��- ❑ Industrial ❑ Open Bottom 770' Man teca Dia. I Ei2cavation --9— T of CasingSpecifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype Type ❑ Public ❑ other } ❑ Delta Depth of Grout Seal of Grout El Irrigation �pprox. Depth ❑ Ea�tern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. '. State Work Done .a Well Destruction ❑ Well Diameter Sealing Material (top X50'} G Depth Filler Material (Below�50') ittUJ I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION fESTRUCTION ❑ (No septilable system perm ed'rf public sewer is Installation will serve: Residence Commercial_ Other i Number of living units: Number of bedrooms t � 3 Water table depth Character of soil to a depth of 3 feet: t�,a No. Compartments SEPTIC TANK ❑ Ttype/Mfg Cal#acity PKG. TREATMENT PLT. C3 ` j Method of Disposal Distance to_nearest:_ ._WeIL---._—�— Fouirdati�n Property Line J D F T t I gth/size l f Z r " LEACHING LINENo. & Length of lines `y ❑ Distance to nearest: . Well Foundation. Property Line FILTER BED -iA ar r; S* 4 mbar SEEPAGE PITS ❑ Depth' r . t _ Property Line SUMPS ❑ Distance to hearfst: Well 1 Foundat`on DISPOSAL PONDS ❑ 1 i { I hereby certify that 1 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: "1 certify tfi it in 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 Califomiai"Contractors hiring or sub-contracting signature certifies the following:"1 certify that in the performance of the work for which this permit is issued, employ persons subject to workman's compensa- tion laws of California." �t The applicant must�cll re sire¢ i ions. Complete drawing on rave side. 3--z�-�� Signed Title: �M1 Date: g FOR DEPARTMENT USE ONLY pt Date Area `•� Application Accepted by Date_ Final Inspecdi n by Date Pit or Grout Inspection by !r Additional Comments: ❑ 5tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tacy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1801 E. Ha elton A,na., P.O. B x2009, Stk., CA"952U1 f ' FEE CK RECEIVED BY DATE PERMIT"NO. INFO AMOUNT DUE AMOUNT REMITTED CASH ref 3 + EH 13-24(REV.1/s 5) - O � EH 1426