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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 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.548 for sewage or No. 16&2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address f S. "�,J0_E/Z�E�srt6rs a 41 City Lot Size �4A ii . PM Owner's Name �.l-+yf[[ '"14e4c+1/ Address/�7�S J��+� Phone Contracto Address Vill 6017b02 License No.Af 4 Phone_ TK1�.QF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAR TIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDA AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca . of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type o Specifications ❑ Public n Other Ll Delta Depth of Grout Sea Type of Grout I I Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done L1Type of Pump H.P. _ State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 { Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIRIADDITION DESTRUCTION I I (No septic system permitted if public sewer r-01177available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: _L— Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth �G SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines $ Total length/size FILTER BED ❑ Distance to nearest: Well SQ ! Foundation /0 z Property Line 5 SEEPAGE PITS I 1 Depth Size — Number SUMPS ❑ Distance to nearest: Well Foundation Property line DISPOSAL PONDS ❑ 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 Diltrict. 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." 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 must call for all required inspections. Complete drawing on reverse side. Signed X Title:�e4 O_C4. Date: FODEPART ENT USE ONLY Application Accepted bV DateArea Pit or Grout Inspection by Data Final Inspection by Hate� ` 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. Box 2009, Stk., CA 95201 FEE CK 4k INFO AMOUNT DUE AMOUNT/R�EIM�ITTED CASH RECEIVED BY r DATE n,�y PERMIT'NO. +.EH 13-241REV.1/H51 7D r- j y 1 y *-� y a ,104 EH 14-28 C ��/YY S+V V 0 L