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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i 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 R�ulati�of the San Joaquin Local Health District. A/ i/O /V � Job Address City�I-rrw _ Lot Size 4#1) 1_a11..q_ PM Owner's Na �l; '' "'!�_ Address Z1 ��LQ d �tH.�,�/� Phone Contracto t �'fl-_ Address 1'+�C b 1_ 4License No.3_ (c� Phone_ TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT [7, UCTION ❑ L TPUMP INSTALLATION ❑ _ '_ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WE OTHER WELL_____ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA NSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mai Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ T y Type of Casing Specifications ['1 Public ❑ Other Delta Depth of Grout Seat Type of Grout I I Irrigation _Approx, th l ! Eastern Surface Seal Installed by Repair Work Done ❑ Type of mp H.P --State Work Done Well Destruction ❑ Diameter Sealing Material (top 50'I Depth Filler Material IBelow 501. _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDI`TION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence—L1 Commercial Other _ p Number of living units: V_ Number of bedroom //s�� Character of soil to a depth of 3 feet: � _L 011 Water table depth_ 0 SEPTIC TANK ❑ Type/Mfg C-40,12 Capacity 16clio No. Compartments 7-- PKG. TREATMENT PLT. U Method of Disposal t Distance to nearest: Well Foundation S Property Line _ �/ Length lin Total len th/size 1 o LEACHING LINE L� No. & Leng of es �__,�__ 9 �- FILTER BED ❑ Distance to nearesCell Foundation_ n Property Line SEEPAGE PITS I I Depth A Size _._-.Z J Q Number SUMPS LW*"Distance to nearest: Well oundatioProperty Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that he work will be done in accordance with Sari 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 all for all rregquire speetions. Complete drawing on reverse side. /_7——/ Signed X�G�1� _ _ __. _ __ Title: __ Date: �' FOR D PA MFT ENT USE ONLY Applicati Accepted by —.._ _ —__-__ ___ _ Dato Area Pito out n lection by Date��Final Inspection by �� Date Additional Comments: — ;[T [I Stk 466-6781 ❑ Lodi 369-3621 D Manteca 823-7104 Ci Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DU£ AMOUNT REMITTED CASH RECEIVED BY DATE PERTO. INFO /r�� EH I!24 tREV.i x 5i -�(1 19/.el _nL