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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 (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 City Lot Siz w'�''f• PM Owner's Name Address / /Phone _c� Contractor r dress / /� S LG QJ'yI ; License No. r k Phone 9 I V TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAI OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWELINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRIC LTURE L OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WEZEITr CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open BottoDia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel PackType of Casing Specifications f'1 Public ❑ OtherDepth of Grout Seal Type of GroutI I Irrigation _-Approx. DSurface Seal Installed byRepair Work Done ❑ Type of Pump State Work Done Well Destruction ❑ Weil Diameter Sealing Oaterial (top 501 Depth Filler Material f Belo ) TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DES UCTION I 1 IN septic ystem permitted if public sewer is C / ilable chin feet', Installation will serve: Residence— Commercial Othera ul" Number of living Un-iii:___. Num1er of bedrooms 4, �4 / O Character of soil to a depth of 3 feet: / Water table depth SEPTIC TANK ElType/Mfg Capacity6 00 No. Compartments PKG. TREATMENT PLT. ❑ Method of Dispos Distance to nearest: Well —Wk.undation Property Line LEACHING LINE ❑ No. & Length of tines 17 To length/s e FILTER BED ❑ Distance to nearest: I 1�O atio Li r SEEPAGE PITS I I Depth Siz00 Number SUMPS I_I Distance to nearest: F anon Property Line DISPOSAL PONDS I� 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 Di§trict. Home owner or licensed agent's signature certifies the following: ,l 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 st call for aj1,wJuired in pec ions. Complete drawing on reverse side. Signed X 1=4 Title: Date: ~ Z2 OR DEPARTMENT USE ONLY Application Accepted by Data 13~ Are Pit or Grout Inspection by Date Final Inspection bK. Dated 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. Bax 2009, Stk., CA 95201 FEE INFO MOUNT DUE AMMO/UNT REMITTED CCK RECEIVED BY DATE PERMIT'No. + EH 13.24(REV.r/x 5) L'.1 raf'�) /I 49 ^ �y EH 14-26 V t/ ( f t JC4LIV T Ola—G� L v V