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} I , foie 7 f& APPLICATION FOR PERMIT CJ mE N JOAQUIN LOCAL HEALTH DISTRICTg • 1601 E. HAZELTON AVE., STOCKTON, CA 4 4-4,4-V C aY Z-d _h,ft Telephone (209) 466-6781 N\4) ��"'� '`� "PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -c... �,r,, ,. 2 (Complete in Triplicate) AppG1.�c I'C �u�/ H lication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.TWs 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 i Local Health District. Job Address � � f— Ycity_5y_bC&W7J Lot Size .- PM Owner's Name 2—v g -5g;Q excv,Address R Phone6 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWSNE5 DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULT E WELL OTHER WEL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO TRUCTION CATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. o Excavation bio. of Well Casing ❑ Domestic/Private D Gravel Pack D Tracy ype of sing Specifications ❑ Public ❑ Other ❑ De Depth of G t Seal Type of Grout ❑ Irrigation ---Approx. Depth Eastern Surface Seal I tailed by r Repair Work Done D Type of Pum H.P. State Work Done_ Well Destruction ❑ Well Dia er Sealing Material (top 50') Depth Filler Material {Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is Installation will serve: Residence_ Commercial, Other available within 200 feet.) Number of living units: Number of bedrooms ^ — A Character of soil to a depth of 3 feet: a' t Water table depth SEPTIC TANK Type/Mfg l Capa;ity No. Compartments PKG. TREATMENT PLT. ❑ m z Method of Disposal Distance to nearest: Well.a 'FoundationProperty Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation ~ Property Line SEEPAGE PITS ❑ Depth ' Size Number / SUMPS ❑ 'Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ o hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state rules and regulations of the San Joaquin Local Health District. laws, and Home owner or licensed agent's signature certifies the following: "I c4kfydhat 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 I 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." T 8a licant m . call for all required inspegtions. Complete drawing on reverse side. Signed) G- t a Title:' Date: 3 FOR DEPARTMENT USE O Y Application Accepted by 1 ' � v r Area Date Pit or Grout Inspection b Date Final Inspection by ' Date Additional Comments: r ❑ Stk 466-6781 D Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 8354M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK `"RECEIVED INFO CASH BY DATE PERMIT NO. + EH 1324IREV,1/e Sl (��U 8 $; _ -r6 7 � EH 14-28