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.� APPLICATION FOR PERMIT y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 u C-) Sr, u �� 40 j City �1 r4G)I Lot Size PM Owner's Name �I ai7� 19Ce)&VA Address Gid{1 Cf1 fj!10 IA/ k-9/ IFS-41-44-hone • Contractor tt,.[ 1 Address _ OY4q 9 License No. 9'7 Phone a te✓ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM 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 PROBL AREA STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ T y Type of Casing Specifications M Public n Other Delta Depth of Grout Seal Type of Grout I I Irrigation _-.Approx. De i I Eastern Surface Seal Installed b11 Repair Work Done ❑ Type of Pum H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION K REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: + Number of bedrooms Character of soil to a de�pthh f 3 feet: inn 4)Q. Water table depth SEPTIC TANK Lrl Type/Mfg 10+:L C006fe-4--C, Capacity _ No. Compartments - PKG. TREATMENT PLT. ❑ Method of Disposal 3 ' Distance to nearest: Well �a (1 Foundation v Property Line (N} LEACHING LINE V---No. & Length of linesTotallength/size v i' T" FILTER BED CIDistance to nearest: Well �� Foundation_ Property Line SEEPAGE PITS I I Depth Size Number .r SUMPS L1 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, 1 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, I shall employ persons subject to workman's compensa- tion laws of California." w The applicant must call r all requir d inspections. Complete drawing on reverse side. Signed Xt Title: rJ �V1 Date: Application Accepted by /�J� FOR DEPARTMENT USE ONLY y Date oe Area Pit or Grout Inspection by Date Final Inspection by 49M Date /d 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 CK A RECEIVED BY DATE > PERMIT'NO. •�..EH13-24(REV.riNsi riQ� _�l to o EH 14-26 ,