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i K APPLICATION FOR PERMIT '� t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA -- Telephone (209) 466-6781 Ill J ) PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) /^� p ��/�� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hoe ein 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 �„„�.o-P - 4 L(J! &A ice. City SAL Lot Size PM r Owner's NameAddress _ [ o i�`L�`Gl/`!!_/C!� Pho$ Contractor 4 Address z-c,- 3 tis / Q.License 21 —P TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LI PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. FOUNDATION AGRICULTURE WELL OTHER WV PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIONS CATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of xcavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy pe of Casing Specifications ❑ Public Ll Other I ❑ Del Depth of Grout Seal Type of Grout I 1 Irrigation Approx. Depth Eastern Surface Seal Installed by t Repair Work Done LlType of f' H.P. State Work Done_ F Well Destruction e I Diameter Sealing Material Stop 501 Depth t Filler Material'(Below 50')- TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION I 1 DESTRUCTION No septic system permitted if public sewer is vailable within 200 feet.) �J Installation will serve: Residence# Commercial Other Number of living units: Number of bedrooms Ik Character of soil to a depth of 3 feet: Water table depth 4` I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, 11 `. Method of Disposal � .; Distance to'nearest: Well Foundation Property Line LEACHING LINE. ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: l Nue11 Foundation --Property-Line SEEPAGE PITS I I Depth 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 regulations of the San Joaquin Local Health District. ` 1 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 taws of California." Contractor's hiring or sub-contracting signature 6 certifies the following: -4 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 applica must call for all require s ction . Complete drawing on re rse side. Signe Title: Date: OR T-USE-ONLY. r ! Application Accepted by � �IkA r Date ____4 ��"� ,T Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: —O_.S SaS=Ysl/ 1 ❑ 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 1 INFO AMOUNT DUE AMOUNT REMITTED C K H RECEIVED BY DATE PERMIT'NO. +-EH 3-24 EH IREV.tiK51 3 _57-- l4-2a � - 97--, 99