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` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 466-6781 ' r 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 YA JYiS/+J&►tV City 77"ACY Lot Size PM Jra r's Name AA Y�' .4 clew Address � _ u Phone } ctor /�iVr v 1S: A',*Addres� P �• gOX �l0 /�aeV7D License No.. J Y�-V / Phone TY OF WELL/PUMP: VV�V0f6Gt i PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ DIS rANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PRO'. LINE Y FOUNDATION AGRICULTURE WELL OTHER WELL PITS tSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �, ❑ Industrial oot'om ❑ Manteca Dia. of Well Excava' Di --o ell Casing i ❑ Domestic/Private l!f�v ac racy Type o asing pec tions ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type out C1.Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by °�E�c� Repair Work Done ❑ Type of Pump H.P. State Work Don �Z Well Destruction ❑ Well Diameter Sealing Material [top 50'1 Depth Filler Material {Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ gESTRUCT10 ❑ (No se tic stem r tte if ublic sewer is avat a e within 200 feet.) Installation will serve. Residence Commercial_ Other Number ofjiving units: ___" Number of bedrooms -7 Character of soil to a depth of 3 feet: �� 1-G Water t blee depth � SEPTIC TANK P1 Type/Mfg 's GA4r Capacity /A atlGo�n�affhlents '�' PKG. TREATMENT PLT. ❑ s X1gtD,04.%fjb osal Distance to nearest: Well /�� Foundation Propbdty Line /010 F LEACHING LINE No. & Length of lines -A Total length/size 40 FILTER BEL) ❑ Distance to nearest: Well 42 � Foundation 'YSProperty Line ! 90 i SEEPAGE PITS ❑ Depth Size 911)( S, X la Number t f SUMPS Wr Distance to nearest: Well Foundation Property Line f DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinani es, state I ws, 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 rformance of the work for which this permit issued, 1 all not /I employ any person in such manner as to become subject to workman's compensation la of California."Contractors hiring or sub-c ntracting si ature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject tow kman's com nsa- �, tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X / G4/` Title: Date: FOR P TM T USE ONLY f Application Accepted by Date �/ 0 Area / Pit or Grout Inspection by Date Final Inspection by Dee 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 �I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. INFO + EH 13-24 1AEV.t 9 51 :0 ! 1 � 7-�1 EN 14-29