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APPLICATION FOR PERMIT �../ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. /7 Job Address �3 kcts S o n ooh /J/31x-City 7`0- C Lot Size PM ¢' Owner's Namethnf/jco 13nr1 FTA( Address 7 ! a y-4 I � I-r�xtc"� Phon40_9-b�34 Contractor -5-04 f 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 PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing p L` ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_. W I I Irrigation —..Approx. Depth I I Eastern Surface Seat Installed by - S Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Welt Diameter Sealing Material (top 50') ._\ W Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION K REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence X Commercial^ Other Number of living units: Number of bedrooms N- f Character of soil to a depth of 3 feet: Water table depth �0 SEPTIC TANK `J�� Type/Mfg Capacity. 0 No. Compartments 2- PKG. TREATMENT PLT.Q' f f Disposal Method of Di sal Distance to nearest: Well �5Q Foundation . Property Line�20 LEACHING LINE ` No. f1 Length of lines 2— Tout length/size FILTER BED El Distance to nearest: Well� Foundation� Property Line_ _s J� - ` SEEPAGE PITS I I Depth Size Number _ SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certity that I 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 I]Mrict. Home owner or licensed agent's signature certifies the following: "1 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 must call for all required inspections. Complete drawing on reverse side. Signedx §ATitle: or✓a.aa— Date: Ala" 13 f9j'% r. FOR DEPARTMENT USE ONLY Application Accepted by ,�� Date Area 1V Pit or Grout Inspection by Pate Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Y.� FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE F;ER:MI�VND.INFO }� 7 EHI}3�IREV.r,xs� 70 / DV cu r�N