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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED i ryl (Complete in Triplicate) r 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 flocal Health District. 'fob Address /fOQO S/j(f LTA �c�44NO;( W City r>At� Lot Size PM III l7wenrs CL,�s�s"��`''f'T S! v LT td Phone Owner's Name tontractor• -� /-1/V CN d SON AddressQ`�pi7b License No. yyy 99/ Phone YPE OF WELL/PUMP: NEW WELL ❑ EMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ EPAIR ❑ OTHER ❑ ISTANCE 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 t7 Industrial t ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications [-I Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout--- . rout_ - I I Irrigation _Approx. Depth 1 I Eastern Surface Seal Installed by - - Repair Work Done ❑ Type of Pump H.P- State Work Done_ ' Well Destruction ❑ Well Diameter Sealing Material (top 50') , Depth Filler Material (Below 501 ,TYPE OF SEPTIC WORK: NEW INSTALLATIONf!P REPAIR/ADDITION I I DESTRUCTION I I INailseptic able waAmem rented if public sewer is Installation will serve: Residence_ Commercial 11' Other Number of living units:_ Number of bedrooms spa Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg per" CNBT Capacity J200 . No- Compartments Method of Disposal I PKG. TREATMENT PLT. ❑ Distance to nearest: Well 300 Foundation ffi0 Property Line Ye t t. f1 LEACHING LINE L7( No. & Length of lines/f 000 Total length/size �� ` FILTER BED [I Distance to nearest: Well Son' Foundation /Soy Property Line-_IWO SEEPAGE PITS II Depth �6� Size 6�d/o'X/O � Number SUMPS (1( 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'orlicensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall nor 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 allrequiredinspections. Complete drawing on reverse side. jSigned X_�...��s•�•-'�f"�wld'• Title: Date: 4g9li DEPARTMENT USE ONLY I ! �' Date �~ Area -/3 i Application Accepted by — I pit or Grout Inspection by D e Final Inspection by-lI Date t Additional Comments: ❑ 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 I I FEE AMOUNT DUE AMOUNT REMITTED CASH 1k/RECEIVED BY DATE PERMn'NO, INFO I �-� _ ra . 11JG� �oa�,