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APPLICATION .FOR PERMIT 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ' •, (est� �' Job Address City Lot Size PM Owner's Name l ��_ Address LzaAwf Phone Y9.2— Contractor v b .y Address,f= i EL 7KO L.icense.Np��Phone m TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Q SYSTEM REPAIR ❑ OTHER ❑ .- DISTANCE TO NEAREST: SEPTIC TAMC 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 C) Gravel Pack = 0 Tracy `7 .Type-of.Casing Specifications ❑ Public , 1-1 Other Cl Delta Depth of.Gtout-Seal Type of Grout Id Irrigation - I+w - _:Approx. Depth .1.1 Eastern Surface Seal Installed by Repair Work Done ❑. Type of-Pump A H.P.. State Work Done Well Destruction El, Well Diameter Sealing Material (top 501 V� — 'Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION DESTRUCTION I I Mo septic system permitted if public sewer is available within 2 feet.► i Installation will serve: Residence a'�- Commercial � Other � /3�„��p� � r`�,a.�ok Number of living units: � Number of bedroom_. - - (�'� X Character of soil to a depth of 3 feet: d .rf U Water table depth SEPTIC TANK Type/,Mfg Capacity 1:2 0 0 No. Compartments PKG. TREATMENT.PLT. ❑ '�'� Method of Disposal _NDista_Ze'to nearest:` Well Foundation Property.Line LEACHING LINE ❑ No.'& Length of tines Total length/size FILTER BED T ❑: Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth -. -. . — _._SizeNumber SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I ; 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 anyperson 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 performancii of the work for•which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." } .f " s x i ' - -- The applicant must call for ail required spections. Complete drawing on reverse side. i Signed Title: Date: i f FOR DEPARTMENT USE ONLY Application Acce ted b PP P Y � ..�_ Date � � Area Pit or Grout Inspection by Date Fi spection by j�Date Additional Comments:v _ -' ! at-n 14 /�,S D y ew ' ❑ Stk 466-6781 q ❑ Lodi 369-3621 . ❑ Manteca 823-7104 - ❑ Tracy 635-6365 Applicant -.Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95.201 f INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY D/AI^TE pERM1T'NO. +.rE2,0 r 13-24 IRa v.r i K 51 CJ. �\ /A y y e7d EH 14-2e �J ( ! r