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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 `z076 ee Gel4e_ City T Ife Lot Size//O f)(/-5 Owner's Name �LAddress Phone Ca tractor Address `9 F6' License No.,:: �) Phone -zC/ TYPE O LMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ --PNf11lI�NST�ALLATION ❑ SYSTEM REPAIR ❑ OTHER C1DISTANCE TO NEAREST: SEPTIC TA SEWER SEWER LINES DISPOSAL FLD. PROP. LINE- FOUNDATION ICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well ion Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications * Public f7 Other ❑ Delta Depth of Grout Seal Type of Grout _. I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by ` Repair Work Done L3 Type of Pump H.P, State Work Done G Well Destruction ❑ Well Diameter Sealing Material (top 501 a}.� Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I INo septic'sgstem permitted if public sewer is available within 200 feet.) Installation will serve: Residence v/Commercial— Other- f l}et1 Number of living units: Number of bedrooms Z 1 nT ! Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg / !'rlVC, Capacity 16'40'_57 No. Compartments PKG. TREATMENT PLT. ❑ O Method of Disposal C f{�� Distance to nearest: Well Foundation Property Line I LEACHING LINE No. 8 Length of lines Total length/size �``rr�i FILTER BED ❑ Distance to nearest: Well Foundation . Property Line� SEEPAGE PITS )( Depth 7-S—Fr Size 37 5' _� Number _Z_ `ti SUMPS L1 Distance to nearest: Well f�� Foundation �-)� Property Line /O ! DISPOSAL PONDS O 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 District. 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 cosPly 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 c r all requ�ompleta drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by 0 1 Data Final Inspection by r U -n`e-? ,/ Dat r'� Additional Comments: � V-5415* Jn f?74*- /a � G Of �" &"f -l��_e-&0-) ❑ Stk 466-6781 ❑ focli 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO —'j``�� /� CASH ` p-� 7 �j ♦ EH 13-241REV.i/H 51 ! V (1� X41, 1 C 0 —a— s� �! •"' 6 9-5 EH 14-2a !