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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601`E..FIAZELTON 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 combuct and/or Install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No.180 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. - Jab Address ✓ t�D / Oil YJ 1AAA! v(Y city 6arp-_X Lot Size %5,ry C+ PM Owner's Name (SlAR r 310MfE4ddrsae'/1. a _z1+Oh Contractar LG C� L/C Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM fl AIR ❑ .z OTHER Ai pft�i DISTANCE TO NEAREST: SEPTIC TANK SEWER ES,. 1 DISPOSAL FLD.� PROP. LINE FOUNDATION AGRICULT WJOLL OTHER WELL' PITS/SUMPS INTENDEDIISE TYPE OF WELL PROBLEMAREA C e RUCTION SPECIFICATIONS- ( t ❑ Industrial -❑'Open Bottom^0-Manteca--- '6f Excavation Dim;of Well C 8N -❑ Domestic/Private ❑Gravel Pack ❑ Tracy T yiAIof Cadn SpetiRestiorts ❑ Public ❑Other ❑ Dela /Depth of Grout al '�,Tips of GrSUt — ❑IrrigationAppmx. DBPt h ❑ �! Surface Seal Installed by Repair Work Doris ❑ Type of Pump x�` c -� ,H•P� I State Work Done �d Well Destruction ❑ Well DiameterSealing Material Itop SIT) W D'.1 ty -, `/ ,Filler Material (Below 50') d TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is ` t available within 200 feet.) q Installation will serve: Reuidence_X Commercial Other Number of living wits:_ Number of bedrooms I_z, Character of still to a depth of 3 teat: ' Water table depth SEPTIC TANK f3 Type/Mfg1 ' Capacity--o-M-0— No. Compartments a PKG. TREATMENT PLT.❑ 1 „r Method of Disposal Distance to nearest: Wel l'-I Foundation 10 Property line 30 , LEACHING LINE 0--No.6 Length of lines +- - _ Tytal length/size FILTER BED ❑ Distance to nearest: WallTT3 Foundation�LW_ Property Line 000 SEEPAGE PITS ❑ Depth Size Number _--.__ SUMPS ❑ 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 menner 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 m s all for all q ed inspections. Complete drawing on reverse side. , �y Signed X Title: —p.�i+��-- Date: FO DEP MENT USE ONLY Application Accept by Date —�^ `�^' Area j//,y Pit or Grout Inspection by Final Inspection b �,L��Q Damb I Additional Comments: ❑ Stk 466-Ml ❑ Lodi 369-3821 ❑ Manteca 823-71 ❑Tracy 835.8385 Applicant - Return all copies to: Environmental Health Permit/Services 1SDI E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT NO. p ly1 , EN t1D11REV.iin51 1o•p0 �E'I',I� cu ux