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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.1882 for well/pump and the Rules and Regulations of the San Joaquin Local Health Distri�ctt.. { J , /� Job Address �Q/ �/ 4a �t Id City y1 Lot Size Z-412 IC-1— PM Owner's Name 44-hAddreas _�/T�r .� . _ Phone Contractor's Name License No. ZY3A 3 a Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES "SAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS INTENDED USE TYPE O ELL PROBLEM AREA CONSTFIJMfION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. all Excavation pia,of Wall Casing ❑ Domestic/Private ❑ Gravel Pack cy of Casing '' Specifications Cl Public ❑ Othar ❑ Dena th of Grout Seal Type of Grout _ ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal lfista Repair Work Done ❑ Type of Pump P. State Work Done Well Destruction ❑ Well Diameter) Sealing Material(top 50') ' Depth Filler Material(Below SO'] TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewar is ' ! available within 200 teat.) Installation will serve: Residence /— Commercial - Other Number of living units:4— Number of be ones Character of soil to a depth of 3 feet: CZAALL 4z&9 L +' Water table depth SEPTIC TANK ❑ Type/Mfg FI Capacity No. Compartments PKG.TREATJ4 ENT PLT.❑ _ { t Metfiod of D�isp� I 12 C(.°7,1�j►"�1 Distance to nearest; Well 0 Foundation ` Property Une Z-6 » LEACHING LiNE J6. No. &Length of lines Total length/size -° FILTER BED ❑ Distance to nearest; Wal! ',Foundation j % Property Line SEEPAGE PITS ❑ Depth Size 47rx Nujnber )5-SUMPS Distance to nearest: Wel! Foundation Property Line 0071— DISPOSAL PONDS 0 � 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 perforrnar"of the work for whicfi this permit is issued,I shall not employ any person in such manner as to become subject to workman's compensation laws of Calitomia."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 laves of Cal mla", The appilcent rw call for fill required inspections.Complete drawing on reverse side. Signed Trtle; Dater FOR DEPARTMENT USE ONLY Application Accepted by Data •- Area d �� !I Pit or Grout Inspection by Date Final Inspection by Date7 1 Additional Comments: ❑ Stk 468.5781 ❑ Lodi 369.3621 ❑Manteca 823-7164 ❑Tracy 93583M Applicant- Retum all copies to; Environmental Health Permit/Services 1601 E. Hazanon Ave., P.O. Box 2004, Stk., CA 9SM1 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY. DATE PERMIT`NO. INFO +SH 18&21 iREV.10/0 �D. JY] i 14 I cr '7 EH 1445 I G 6 t