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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. / 7/ y rjCSs r / c 17tC t fir) tY�' 717_TA S,z'M Job Address� � � � Fn' ``� �/ City c6��L h� Lot Size' X ��- PM Owner's Name `h1c, q:'- toa Addressi I 7 "z -74.,` Phone Contractor � � Address rr 7 /u�L License No.-3Z IFLZ� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DES CTION El INSTALLATION El SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES D OSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CON CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public F1 Other n D Depth of Grout Seal Type of Grout I I Irrigation .Approx. Depth Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diame Seating Material (top 50') Dept Filter Material (Below 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION le REPAIR/ADDITION 1 I DESTRUCTION 1 1 (No septic system permitted if public sewer is 1� available within 200 feet.) Installation will serve: Residence X Commercial_ Other Number of living units: --I— Number of bedrooms VN Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK (ff'Type/Mfg & Capacity 411W No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well lSC Foundation s Property Line S LEACHING LINE No. & Length of lines .7' L7 Total length/size I I,C, I x V z FILTER BED ❑ Distance to nearest: Well I e G Foundation ! L` Property Line S SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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, 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, I 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 >t v-L.LT C Title: Date: R DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by ate -7 � 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 RECEIVED BY DATE PERMIT NO. / + EH 13-24(REV.s i n 5) � EH 14-26 �/10