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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT iL 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781- PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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. I ,/ Job Address 38�� SEC Tf0![l City � O�PGA1 Lot Size PM m # Owner's Name S;X.(a!D C'/fdress 3 /901'W C-T -S7—Sow JOSE Phone Contractor SE��" '" # Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL S INTENDED USE TYPE 0 PROBLEM AREA CONSTRUCTION SPE 5 f ❑ Industrial ❑ Open Bottom ❑ Mantec Dia. vation Dia. of Well Casing ❑ Domestic/Private r .❑Grave! Pack ❑ Tracy Type o Specifications I'l Public ❑ Other elta Depth of Grout Seal Type of Grout t I I Irrigation Depth I I Eastern' Surface Seal Installed by _ # _ Repair Work Done ype of Pump H.P. State Work Done, Well Des n ❑ Well Diameter Sealing Material (top 501 l Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIWADDITION l-1 DESTRUCTION (No septic system permitted if public sewer is � [ vailable within 200 feet 1 Installation will serve:r Residence�_ Commercial._ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth " SEPTIC TANK I Type/Mfg Capacity No. Compartments ' PKG..TREATMENT PLT. ❑ t Method of Disposal Distance to nearest: Well Foundation Property line ~ LEACHING LINE } ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to dearest: Well FoundationProperty Line j :_ ..,..�.. � 111, SEEPAGE PITS I I Depth Size Number 1 SUMpS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS..Y ❑ 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 g 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 Pt call for all required in pections. Complete drawing on r arse side. Signed X Title:_ Date: .6 ��"�7_ FOR DEPAR1ENT,USE.ON Y V` U 1 I Application;Accepted by Date r Area Pit or Grout Inspection Date Final Inspection by Date ._Additional Comments: ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 :F>� FEE AMOUNT DUE k AMOUNTREMITTED INFO SH RECEIVED BY DATE PERMIT•No. r EH1 3-24IPEV.I/H 51 EH 1428 - ........JJJ�"---»> "/ ►p!/ '