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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. / + Job Address /'3-1200 SIS v r City ryT Lot Size PM y Owner's Name OW EIVS Gl A SS 1p�Iii!/ Address S O S 1 v L re aj-d Phone Contractor 407 144'7 )OAl 'd SOH Address 010.7 Stive-1, I7dpf7b License No. 9,W 49! Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL EPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ STEM REPAIR ❑ OTHER ❑ DISTANCE 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f"1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth ( 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') O Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION,/4 REPAIR/ADDITION t I DESTRUCTION I I (No septic system permitted if public sewer is d available within 200 feet.) Installation will serve: Residence_ Commercial-!K- Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Hcg✓Y X ot}rrr Water table depth SEPTIC TANK 0 Type/Mfg '0�Jf Capacity 1.200 No. Compartments �+ PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Sop Foundation -Oe Property Line Ye LEACHING LINE IZ4 No. & Length of lines/ 1 60 Total length/size fro' FILTER BED ❑ Distance to nearest: Well JAI' Foundation /fid' Property Line SEEPAGE PITS I I Depth 1e Size _b'X l e"X IV r Number 1 SUMPS LK Distance to nearest: Well Foundation Property Line DISPOSAL PONDS n 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."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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: /Jr'_" FR DEPARTMENT USE ONLY Application Accepted by Date C~' / Area AT Pit or Grout Inspection by D A Final Inspection by -^� Date 4 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.i i it 5)