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a v. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 9601 E. HAZETON AVE., STOCKTON, CA : Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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 I Local Health District. 1 , Job Address ' r City ,7 Lot Size PM c U E O r � Owner's Name K4�dtess C7 Phone Contractor Address License No. Phone->' :57- TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION d SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SE LINES POSAL FLD. PROP. LINE FOUNDATION AGRICUL RE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO T TION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca o ell Excavation Dia:of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Cad" g Specifications 1-1 Public ❑ Other ❑ Delt Depth of Grou eal Type of Grout I I Irrigation __Approx. Depth astern Surface Seal Insta by " Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction . ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION € I DESTRUCTIO (No septic system permitted if public sewer is `} available within 200 feet.) Installation will serve: Residence`'K Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth A SEPTIC TANK .❑ Type/Mfg ' Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well f=oundation Property Line LEACHING LINE ❑ No. & Length df lines 'Total length/size FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line ` SEEPAGE PITS f I Depth Size Number ppp SUMPS 0 Distance to nearest: Well Foundation Property Line h DISPOSAL PONDS ❑ J 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 tv 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, 1 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,t shall employ persons subject to workman's compensa- tion laws of California." The applica ust call for all re uired inspections. Complete drawing on reverse side. Signed X �� Title: Date: `�Z �C C\A L3 FOR DEPARTMENT USE ONLY t g' Application Accepted by Z bate �2 197 Area l v # Pit or Grout Inspection by Date Final Inspection by_ell:� .0 d_ Date 3 p t Additional Comments: Q cr, ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 e_514ep� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201FEE 1� I INFO AMOUNT DUE AMOUNT REMITTED AS RECEIVED BY DATE PERMIT'No. '�1 I + EH i3-29IREV.Iin51 . EH 14-26