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{ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA r: Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I. (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. a Job Address _ L y n ^^ 3i City Lot Size PM s Owner's Name w• Address �" Phone Contractor ��!ss�ddress `� License No. C` Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA MENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP:-EINE 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 ❑ Gravel Pack ❑ Tracy_ Type of Casing Specifications El Public ❑ Other ❑ Delta Depth of Grout S�_ - Type of Grout El Irrigation Approx. Depth 13 Eastern Surface Seal lnstalled by—" Repair Work Done ❑ Type of Pumpr H.P. State Work.Done Well Destruction ❑ Well Diameter, Sealing Materia top 501 r Depth 'i Filler�Mate ial {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 AIR/ADDITION ❑ DESTRUCTION ❑ (No'septic system permitted.if public sewer is i.. available within 200 feet.)r Installation will serve: Residence— Co�mrmercral� Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:' C4' Water table depth -� SEPTIC TANK [K"T a/Mfg Capacity O No. Compartments i f PKG. TREATMENT PLT.,.O Method of j: I 1 Distance to nearest: Well� Foundation t _�� Property Line LEACHING LINE PIC No. & Length of lines _ Total length/size to C3 t FILTER BED ❑ Distance to nearest: Well g 5 Foundation L n Property Line SEEPAGE PITS ❑ Depth i Size _Number SUMPS ❑ 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 regulation's 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.' Theapplicant.mu IE f r all required spections. Complete drawing on re side. e Signed X �-/iui� Title: Date: d1 F R EPARTMENT USE ONLY Application•Accepted ly, _ ww a ��, Date \�}�� 0`_ 5?�_ Area b Pit or Grout Inspection by Date Final Inspection by 1 > �.(1�- Dat '�� ' Additional Comments:, ❑ Stk 4664781 I ❑ Lodi 369-3621 ❑ Manteca &b-7104 ❑ Tracy 8:354385 Applicant- Return all copies to:Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ,c n FEE 1 AMOUNT DUE AMOUNT REMITTED WH I RECEIVED BY DATE PERMIT`NO. INFO r + Em 4(REV.1/es) j F� �0.�v S �� t(� `n/ ?1V—T07 EH13-21 t 1 l i .