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eS APPLICATION FOR PERMIT Now SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA p- t- Telephone (209) 466-6744• 1-4 6u 3 400 s�, PERMIT EXPIRES TYEAR FROM DATE ISSUED �Xr-.��✓�nr-�f> (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 r� City � Lat Size / Owner's Name ��ornQS a Mc—Cgnn Address ��3 r , ""�,p`^,,'-er QUO- Phone"?�]S` 96 {,� t Contractor +Q Q �� Address (License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR+ ❑ OT ❑ DiSTA EAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r UNDATION k AGRICULTURE WELL OTHER W PITS/SUMPS INTENDED USE TYPE OF PROBLEM AREA CONSTRUCTION SPEC ATIONS ❑ Industrial ❑ Open Bottom ❑ Dia. of Well Exc ion Dia. of Wel! Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy of rng Specifications f 1 Public F1 Other k n Delta pth of Seal Type of Grout I i Irrigation _..Approx. Depth I I Easte Surface Seal Instal e Repair Work Done ❑ Type of Pump H.P. state rk Done _ Well Destruction ❑ Weil r Sealing Material Stop 50'1 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I i DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.) installation will serve: Residence x Commercial— Other Number of living units: Number ofedr om 1 Li Character of soil to a depth of 3 feet: *7 ! Water table depth 0 T SEPTIC TANK Type/Mfg Capacity8ZD0 CkqLy No. Compartments & y� PKG. TREATMENT PLT. ❑ E / 4JJ Method of Disposal Distance to nearest: Well Foundation U Property Line d 60t LEACHING LINE No. & Length of lines fetal length/size a Qk FILTER BED �❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS yC Depth Size 33Ir 1�01, Number SUMPS 11 Distance to nearest: Wel! Foundation J Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate 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 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." 4 1 The applicant must call for ail required inspections. Complete drawing on reverse side. Signed X d e-4m""z./ Title: �G . (� �J. ...___- Date: k7 FM DEPARTMENT USE ONLY ++-- \ Application Accepted bytyr� _ r n. .__t1. Date 1b-8—A /J Pit or Grout Inspect' n by to Final Inspection byZaKfto vct &-s33 Additional Comme 1:1Stk 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, Silk., CA 95201 INFO AfifIOUNT DUE AM NT REMiTTEOFEE CASH RECEIVED BY DATE PEIRJMIT NO. + EH t4-241REV. / EH 11-28 [/