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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address •2 U)• �5 —09/7 "AL City b9AA172�CA Lot Size d/AK ��$ PM Owner's Name Address 370 S7� JV,42� to Phone -S9-13-2 Contractor Address 7 AlADSL e9 .fir Ae/� License No. ��7� Phone i7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DI AREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ION AGRICUL LL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL P TRUCTION SPECIFICATIONS ❑ Industrial - ❑ Open Boit ❑ Manteca Dia. of Well Exca Dia. of Well Casing ❑ Domestic/Private ❑ G Pack ❑ Tracy Type of Casing ecifications i'1 Public Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation ..Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work'-Done Well Destruction ❑ Well Diameter Sealing Material (top 50'I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION DESTRUCTION I 1 IN. septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence 41 Commercial_ Other Number of living units: --JL_ Number of bedrooms 7— G Character of soil to a depth of 3 feet: S 4 A� a Water table depth SEPTIC TANK ❑ Type/Mfg P Q, — P Capacity Zta u No. Compartments �Z— PKG. TREATMENT PLT. ❑ (Method of Disposal Distance to nearest: Well JC0f Foundation )Of Property Line S LEACHING LINE No. & Length of lines 2" 70 z Total length/size i M� FILTER BED ❑ Distance to nearest: Well 90 � Foundation I D r Property Line SEEPAGE PITS l I Depth Size Number SUMPS rLl Distance to nearest:- --Well. Foundation Property Line DISPOSAL PONDS �-❑ hereby certify that t 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." t The applicant must /ccaall for all required inspections: Corpplete drawing on reverse side. a } Signed Xg.,_— -� Title: L O�I _ Date: FOR DEPARTMENT USE ONLY /�f Application Accepted by 'Date i C Area f Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: A-f> e`I2 tl 4-1 0 ✓41,!1,,� - ❑ Stk 466-6781 ❑ Lodi 369-31321, ❑ Manteca 823-7104 ❑ racy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO ASH ' +,EH t3-24(REV.t i N 5) C70 ..«r ry�`� .- r�{r" EH t4-28 10 0. W' •' "i TOZ>�41