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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 __ pQ^ lL�f City �� d Lot Size �l PM Owner's Name Address J Q'H�O Phone !r License No. Phone Contractor �� " Address TYPE- ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t i --�- -INSTAL-l�4TaQN...❑. - -SYSTEM-REPAIR..❑ _. OTHER-G.- DISTANCE TO NEAREST: SEPTIC TA SEWER LINES ^DISPOS FLD. PROP. LINE f FOUNDATION ICULTURE_WELOTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLE REA UCTION SPECIFICATIONS U Industrial°' ❑ Open Batto ❑ Manteca Dia. of Well Exc n Dia. of Well Casing ❑ Domestic/Private ❑ Pack ❑ Tracy Type of Casing Specifications ❑ Public''� ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigatio "Approx. Depth ❑ Eastern Surface Seal Installed by Re ork Done ❑ Type of Pump H.P. State Work pone J Well Destruction [-IWell Diameter r Sealing Material (top 50') N Depth Filler Material (Below 501 r TYPE OF_SEPTIC•WORKY"NEW INSTALLATION-0 REPAIR/ADDITION ❑ „DESTRUCTION No septic system permitted if public sewer is t' f available within 200 feet.) Installation will serve: Residence— Commercial Other i � EE Number of living units: k Number of bedrooms j '' i i' Water table depth ` I Character of soil to a depth of{3 feet: t r SEPTIC TANK- ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ i[i1 Method of Disposal Distance to nearest: Well Foundation f Property Line#l �` LEACHING LINE ❑ No.-&-Length of lines Total length/size FILTER BEDS LJ Distance to,nearest: Well r 1 _.Foundation. F " r'�Property Line _SEEPAGE PITS ElDepth F Size w Number SUMPS ❑ Distance to nearest: Well Foundation--n "Propertyine - - r 'DISPOSAL PONDS ❑ �� z ''` J hereby ci rtify that I have prepared this application and,that the work will be done in accordance with San Joaquin county ordinances, state laws, and f rules and regulations of the San%Joaquin Local HealthfDistrict. 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 ofthe work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." 1 t The applicant must c II for all=required inspections. Complete drawing on reverse side. ' Signed )C t __ - Title�/�l�tircc�— Date .- __. r -- k R-DEPA TMENT USE ONLY t Application� Accepted by r Date Area � Pit or Grout inspection by Date Final Inspection by .. awry 'Additional Comments: 42-2 "`❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy"835 6385 T_ )y C/O' sc ApFplicant'- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 FEEf �� i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. + EH REV.r/$5) �a 1 ko� EH 14-28 ,k