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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE` TON 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. Job Address wott L rA w qqqq A(%rA CP049�:10V - Lot Size Owner's Name Address llqr C449152, UIAV �7&04t,,one Contractor TYPE OF WELL/PUMP: DISTANCE TO NEAREST: nofffil"AE•� 0 Industrial El Domestic/ Private 11 Public I I Irrigation Repair Work Done 0 Well Destruction 0 Iva —�o- Address .6 AA YA;FZ 5�beNoX/27- b Phone 10-131flf C 1 � NEW� WELL E3 WELL REPLACEMENT 0 DESTRUCTION 0 • _41JMP INSTALLATION El SYSTEM REPAIR E) OTHER P�" s Im ere SEPTIC TANK — SEWER LINES — DISPOSAL FLD._ PROP. LINE: FOU TYPF OF WFI I LJ Open Bottom El Gravel Pack n Other Approx. Depth Type of Pump Well Diameter Depth — PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Manteca Dia. of Well Excavation 0 Tracy Type of Casing F1 Delta Depth of Grout Seal t I Eastern Surface Seal Installed by H. P. State Work Done Sealing Material (top 501 Filler Material (Below 501 Dia. of Well Casing Specifications Type of Grout TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION t I DESTRUCTION [ I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence — Number of living units: — Numl: Character of soil to a depth of 3 feet: SEPTIC TANK El Type/Mfg PKG. TREATMENT PLT. El Commercial — Other jf bedrooms, Water table depth Capacity No. Compartments Method of Disposal Foundation — Property Line Foundation Total length/size — Property Line Number — Property Line 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 Diltrict. 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 aptc<ntmust call for all re it d inspections. komplete drawing on reverse side. Z� Signed X Title: Date: 42 —1 R DEPARTMENT USE ONLY -7 Application Accepted by Date 14-1-0 15 Area PitLspection by 46L 4 AM Date td? -4 66 Final Inspection by Date I�Ulbl — - Additional Comments: — 0 Stk 466-6781 0 Lodi 369-3621 0 Manteca 823-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 EH 13.24 (REV. 1/ 9 5 EH 14-26 Distance to nearest: LEACHING LINE El No. & Length of line.,/ FILTER BED El Distance to n7Well 81, SEEPAGE PITS I I Depth 1� -Size SUMPS Ll Distance to nearest: Well DISPOSAL PONDS El Water table depth Capacity No. Compartments Method of Disposal Foundation — Property Line Foundation Total length/size — Property Line Number — Property Line 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 Diltrict. 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 aptc<ntmust call for all re it d inspections. komplete drawing on reverse side. Z� Signed X Title: Date: 42 —1 R DEPARTMENT USE ONLY -7 Application Accepted by Date 14-1-0 15 Area PitLspection by 46L 4 AM Date td? -4 66 Final Inspection by Date I�Ulbl — - Additional Comments: — 0 Stk 466-6781 0 Lodi 369-3621 0 Manteca 823-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 EH 13.24 (REV. 1/ 9 5 EH 14-26