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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. p , Job Address a 7 IJ 16;e _ Lot Size Q GC.G PM Owner's Nam Address ✓� D' ��a //LLLih.L.l-�dpltone 123 -15 71 Z3 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 TYPE OF WELL PRAAREANSTRUCTIONNSTRUCTION SPECIFICATIONS ❑ IndusVial ❑ Open Bottom ❑ , of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ of Casing Specifications F1 Public ❑ Other F1 t of Grout Seal Type of GroutI I Irrigation _.Approx. Depth I I fac Seal Installed byRepair Work Done ❑ Type of Pump State Work Done Well Destruction ❑ Well Diameter rial (top ') Depth Filler Material (Below TYPE OF SEPTIC WORK: NEW INSTALLATION 1. REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) (� Installation will sane: Residence�Cem rcial_ Other I Number of living units: _J_ Number of bedrooms 4 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 9 Type/Mfg T h L Capacity 122 No. Compartments PKG. TREATMENT PLT.❑ t tMethod of Disposal Distance to nearest: Well Foundation Property Line 1!�() LEACHING LINE No. & Length of lines Total length/size FILTER BED El Distance to nearest: Well 11501- Foundation_i� Property Line_rn I _ SEEPAGE PITS H Deplh aS'' Size y � Number .3 SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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."Contractors 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 rt1st call t all req ' ' spections. Complete drawing on reverse side. Signed X ,L,(\� Title: L_-VAII Date: O � PARTMENT USE ONLY Application Accepted by 'YG\�\121 C 6AN DateArea Pit or Grout Inspection by , ' Date Final Inspection by-rc �yL= Date �� 14- / Additional Comments: r': ,/✓ T/� y A7+J ) ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stir., CA 95201 FEE CK INFO OUNT DUE AMOUNT REMITTED CASH RECEIVVEED�BY // DDA/TE /z)�/y+ PERMIT`'/NJ�Ot. • EEN H 1424(RW.r,x 51 ^� C, () I �� I O ( � -0 9�`V