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\ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 7a Job Address Li C Lot Size 7� . PM ZJ Owner's NamAddress rf� � /! /. QPllone 923 -a Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE NT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM EPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER INES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICUL URE LL OTHER WELL PITS/SUMPS _ INTENDED USE ❑ Industrial ❑ Domestic/ Private ("I Public I I Irrigation Repair Work Done ❑ Well Destruction ❑ TYPE OF WELL PROBLEM AREA ❑ Open Bottom ❑ Gravel Pack n Other Approx. Depth Type of Pump Well Diameter Depth u mamecd ❑ Tracy ❑ Delta I I Eastern/ STRUCTION SPECIFICATIONS of Well Excavation of Casinq of Grout Seal 1c Seal Installed by H. P. State Work Done Sealing Material (top Filler Material (Below Dia. of Well Casing Specifications Type of Grout TYPE OF SEPTIC WORK: NEW INSTALLATION 7kI REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is CASH RECEIVED BY available within 200 feet.) Installation will serve: Residence Commercial _ Other D, 0 L Number of living units: Number of bedrooms � ! -71" _r �PPEERMIT�[NO. 7 %!-( _J__ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg �" Capacity � 00 No. Compartments 6 PKG. TREATMENT PLT. ❑ Method of DispoS Distance to nearest: WeII TCDD T Foundation Property Line 1 V T LEACHING LINE No. 8 Length of lines Lotal length/size FILTER BED ❑ Distance to nearest: Well . I uDt Foundation Property Line SEEPAGE PITS I +t Depth as Size V52 // Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 st call f all req yw-;hspections. Complete drawing on reverse side. Signed X Y-Yt�—""�� Title: el-4--� Date: ap n. • F PARTMENT USE ONLY Application Accepted by �'LY CMA •`^ ' k&&CAD IVB Date -1., —C>`rJ Area 9 Pit or Grout Inspection bye' ,/ a ; Date Final Inspection by Date o-/0- Additional Comments: ' h 7 V S l ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 . EH 1124 IREV. EH 1426 INFO OUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE OOO� D, 0 L W L� � ! -71" _r �PPEERMIT�[NO. 7 %!-(