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APPLICATION-FOR PERMIT ze, SAN JOAQUIN LOCAL HEALTH DISTRICT �D 1601 E. HAZE T ON AVE.,,STOCKTON, CA -T61ephone {209) 466-6781 or 16 c� I PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED IComplete 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. - y [ �i�l ``1•¢. zf y CityS I �# Lot Size 7 X /OV, PM 1 Job Address , Owner's Name FR,(4 Address -% i � -' Phone F / v� so�� e. Contractor),A ul,S b < • .l 4- -Address- - - S'f' dG^ ��2 -License-No.� Phone 5 TYPEQF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT '❑ DESTRUCTION ❑ ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAR!! TIC TANK SEWER LINES DISPOSAL FLD. PROP. L1NE FOUND AGRICULTURE WELL 7HER WELL PITS/SUMPS INTENDED USE TYPE OF WELL P AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia_ of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Case Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ; Type of Grout ❑ irrigation �pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter "'"' "� . -Se 6'Material {top 5D'1 Depth Filler Material (Below 501 (j TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) _ Installation will serve: Residence—e.-Commercial_ Other` Number of living units: —Lt— Number of bedrooms �— e 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 A LEACHING LINE ❑ No. & Length-of lines. -- - - -- - - Total-length/size FILTER BED ❑ Distance to nearest: will Foundation Property Line SEEPAGE PITS .-t ❑, Depth S Number SUMPS ❑ Distance to nearest:. L Well J 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, I shall employ persons subject to workman's compensa- tion laws of California." ?+ The applican ust call for all r quired ipspections. Complete drawing on reverse side. Signed cta Ti tie: /�ait1� - . Date 4U e .r OR=DT!�ENT USE ONLY Application Accepted by K Date Area Pit or Grout Inspection by Date Final Inspection by� G. Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE! AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT NO. + EH 13-241RM1/H 51 �s I l EH 1428