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r, APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE.,,STOCKTON, CA Telephone (209) 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r:' r (Complete in Triplicate) i 1 ' Application is hereby made to the San Joaquin Locale 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: L �,/ ^�� j t ,j�_ �� A1;01;110/ Citv:ira ' Lot Size /� PM Job Address I Owner's Name 1ft/� ? /�.T Lam."" Address Phone Contractor �i"r �°t _Address License No. Phone TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATN C> SYSTEM REPAIR ❑ OTHER ❑ ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL PROP. LINE FOUNDATION AGRICULTURE WELL O ELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CON ION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing omestic/Private ❑ Gravel Pack acy Type of Casing Specifications ❑ Public ❑ Oth r ❑ Delta Depth of Grout Seal Type of Grout ❑ irrigation pprox. Depth ❑ Eastern ` Surface Seal Installed by3 1 / �� H,p, `C State Work Done t `fie Repair Work ❑ Type of Pump' Wei truction ❑ Well Diameter f T S I niae g Mat, — e f Depth Filler Material (Below 501 } TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) 9 I Installation will serve: Residency Commercial Other ,_1 Number of living units: Number of bedroo Character of soil to a depth of 3 feet: �� k Water table depth I SEPTIC TANK 1 Type/Mfg Capacity_A_%Qc=L No. Compartments fZ-- PKG. TREATMENT PLT. Method of Disposal El i �� Distance to nearest: Well �� Foundation Property Line ` M ` ZA LEACHING LINE No. & Length of lines Total length/ ize f g s FILTER BED ❑ Distance to nearest: Well' ® f Foundation •' "Property Line�,.a� ' 4r� SEEPAGE PITS Depth A.57 Size -' '' �y�Nyumber SUMPS C1 Distance to'nearest: Well /.«Foundati�f� Property Line DISPOSAL PONDS ❑ ., I ` •"` t I hereby certify that I have prepared this application and that the vfofV will-be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District-.41 - f , 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"Il not employ any person in such manner as to become subject to workman's compensation laws of California.'TContractors•hiring-or-sub-contracting signature certifies the following:"I certify that in the performance°of the-work`for"whici4'"�Fiiii permi` t` isissued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all require' pections plate drawing on reverse sided - Signed Title: �� - -� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date r- A hDate Pit or Grout Inspection by Date Z)1%Final Inspection by A ditional Comments: f "Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 !T_,,Ca Tracy�83&6385 plicant - Return all copies to: Environmental Health Permit/Services 1601 ,E. HazAtan Ave., P.O. Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. INFO + EH 13-24(REV.1/s 51 EH 4428 {