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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I f 1601 E. HAZEL T ON AVE., STOCKTON, CA `�r3 � Telephone (209) 466-6781 4 r� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y (Complete in Triplicate) Application is hetehy 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. r---y / W l Lot Size PM Job Address L©� -_� City ` Owner's Name '�' �j f/l_-1 �7 O 1�eAICI AddressA C0 P/'/1/"(!n -_-_-__ Phone 3 ' Contractor Address License No. Phone _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ " -DISTANCETO T: -SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FO N. AGRICULT WELL - , INTENDED USE TYPE OF WE M AREA CONSTRUCTION SPECIFICATIONS 4, t , ❑ Industrial ottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing- ' r ❑ Domestic/Pri ❑ Gravel Pack ❑ Tracy Type o Specifications F1 Publ' ❑ Other ❑ Delta Depth of Grout Se J Type,of Grout r I I Irrigation _.-Approx, Depth I I Easter Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 r Depth Filler Material (Below 501 t TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIR/ADDITION I 1 DESTRUCTION^N`&-septic system permitted if public-sewer=is�= available within 200 feet.) "' Installation will serve: Residence_ Commercial_ Others" Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size - FILTER SED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS L1 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, f 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. Q3 Signed 41- Title: _ �� - Date: S_ t/V FOR DEPARTMENT USE ONLY Application Accepted abyy Date cArea Pit or Grout Inspect Date Final Inspection by "S�° Kr' I-9-4'.0 Date a9 ?0 -�-Q- — ��1/� Additional Comments: a n e LTJ / ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 IS Gc,�e 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) I CASH RECEIVED BY DATE PERMIT-NO. +.EH"19-24(REV.i i n 5} 35 d �yW 1.3• '�\ I sv e S EH 14-26