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i ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 i PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) i 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 _ 1 Z!0 �• �e�so'� 'v City S ��' � Lot Size �aC+ PM Owner's Name RQIck, Address 7�3 � ®� �e- Phone Contractor R,,�V%0_ lColbft �1.1es Address LIZ3 N► `a a License No. VW—'7� Phone 8; 3-CLF24 I I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WE OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PR BL<AREANSTRUCTION SPECIFICATIONS❑ Industrial ❑ Open Bottom ❑ M fWell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracof Casing Specifications n Public ❑ Other I Cl tof Grout Seal Type of GroutI I Irrigation Approx. Depth Eastce Seal Installed byRepair Work Done ❑ Type of Pump State Work Dane + Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Y Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 04 REPAIWADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is 1 available within 200 feet.) Installation will serve: Residence x' Commercial— Other Number of living units: 4- Number of bedrooms a * 1! Character of soil to a depth of 3 feetG G Water table depth f+ SEPTIC TANK f]� Type(/Mfg 42AU If Capacity__LS"O No. Compartments PKG. TREATMENT PLT. ❑ 'a Method of Disposal 4 Distance to nearest: Well Foundation l� Property Line -10c i LEACHING LINE 0 No. & L ngth of lines 'Z" S� Total length/size 0 FILTER BED ❑ `,Distance to nearest: Well—9,,00 Foundation Property Line i SEEPAGE PITS I I Depth I Size zi � Number SUMPS ❑ Distance to nearest: Well-..,pZ Foundation �c�� Property Line 900..1 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, 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 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: _ E7 �C�[� ^ can{� f Date: - q� FOR DEPARTMENT USE ONLY [ Application Accepted by �1]]VW Date Area Pit or Grout Inspection Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 k - FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO ��/ S wEH14-241REV.tiy51 �© �v, LTU �I�(1I- �S j EH 14-28 f C/C/