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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. ,. 3 �.7 , Job Address s • �yr�sr�,� r�� ^"" .City--c��"Lot Size � Owners Narr��u �r�'•,y � Address `- �(a f �� t�7 ��' Phone / Contractor - �'s'" - Address I? s""" License Ho. - Pnane �¢ �� TYPE OF WELL/POMP: NEW WELL D ' WELL REPLACEMENT D DESTRUCTION D J��ump,, INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER EJ DISTANCE TO NEAREST- SEPTIC'TANK SEWER LINES DISPOSAL FUD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WEZL .PROBLEM AREA CONSTRUCTION SPECIFICATIONS - DJ Industrial ❑ Open Bottom D Manteca Die. of Well Excavation Dia. of Well Casing Ol Domestic/Private ❑ Gravel Pack D Tracy Type olr-asing Specifications ❑111111 Publid - ❑ Other ❑ Delta Depth.6f�out Seal Type of Grout ❑ III rdgation � ' ---Approx. Depth ❑ Eastern- Surface-Seal Installed by R it Work D�io^ne D/ Type of Pump H.P. - .�L�. State Work Done_ W 11 Destructlbn © Well Diameter Sealing Mate'a[YNop 50'I - Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ 'REPAIR/ADDITION DESTRUCTION ❑ (No septic system Permitted if public sewer is available within 200 feet.) InstallatioTlyyill serve: Residence_ Commercial_ Other 1 % - �Y Number of living units: Number of bedrooms GG { S, Charactenof soil to a depth of 3 fear. Water table depth SEPTIC TANICJ ❑ .SYMIMfg ,fit t 1 �pachy No. Compartments F PKG. TREATMENT PLT.0, y ' +. r Method of Disposal) DistanceAo-nearest: Weil L Foul atmn '+ Property Line �} f _ 1 ' I talien length/size- 4 LEACHING LAE tYNo. & Length of lines ToC gt FILTER BED'; 1. ❑ Distance.to-nearestWel1l _ Fo daD3n�;� Property Line G SEEPAGE PITS' CT Depth ` ,.,� Size � Num r •- -T SUMPS . : D Distance tnearesr. We1F.: 1 ,�Fouhdation_�Q Property Line DISPOSAL PONDS 1 ❑ I hereby certify that I have prepared this`application and that the work will done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San*Joaquin Local.Health District. .. p-, - ': Home owner or licensed agent's'signature certifies the following: ri's'Hcr"I pertify that in the performance of the work for which this permit is issued, I shall not employ any person in such mangler as to become subject to workmahmpe�sation laws of California." Contractor's hiring or sub-contracting signature certifies the following: '.'I certify`draTm-the of the wbirk for wh(c'i is permit is issued, I shall employ persons subject to workman's compensa- tion laws of Californil t - The applica must sllsfo�r�all�r uirad i pact- s. Complete drawing�on reverse side. Si x '7-rr�r L7?l!�- Title: /�t� VDate: 1. e FOR DEPARTMENT USE ONLY Application Accepted by Data �^ Area Q E 1 _0 1 1"—Pit-or Grout inspection by Data Final Inspection Dy D��_ Additional Comments: t D Stk 4666781 ❑ LOdi- '369-3621 t-O-Manieca 823-7104) 0`Traey. X835-6386 Applicant - Return all espies to: Environmental Health Permit/Services,1601 E.'Hazehon My P.O. Box 2008, Stk., CA 95201 INW AMOUNT DUE FAMOUNT REMITTED CASH REC/EIVED BY DATE PERMIT N0. ♦ EH'}N 1REV.1/flat (J '0r4