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f APPLICATION FOR PERMIT ( SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I'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 V � �' � ��7/� .4Ge City 07l1t fa Lot Size PM Owner's Name ✓lam��GG-� L �0��Address f �' � �✓ �s('a 5L ' 3 73--1 Phone 1 Contfactorlz;525/_� Address License No. Phone \TYPE OF WELL/PUMP: NEW WELL ❑ ELL REPLACEME T ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM R AIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN DISPOSAL FLD. PROP. LINE l FOUNDATION AGRICULTUR *W OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO TRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca D' . o Well Excavation Dia. of Well Casing ' ❑ Domestic/Private ❑ Grave! Pack ❑ Tracy ype o Casing Specifications F] Public ❑ Other ❑ Delta Depth o Grout Seal Type of Grout _ I I Irrigation _._Approx. Depth { I Eastern Surface Sal Installed by Repair Work Done ❑ Type of Pump H State Work Done _ Well Destruction ❑ Well Diameter ealing Material (top 50 Depth Filler Material fBelow 50'1 A_ ,TYPE OF SEPTIC WORK: NEW INSTALLATION' REPAIR/ADDITION f I DESTRUCTION I I (No septic system permitted if public sewer is (� available within 200 feet.) Installation will serve: Residence— Commercial_ Other { Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg _[�_4L[' l ,��! � Capacity -d ?No. Compartments r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE IN No. & Length of lines total length/size X FILTER BED ❑ Distance to nearest: Welf" Foundation �7 Property Lind:: I SEEPAGE PITS I I Depth Size Number ! SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that t 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 theiv✓ork 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 p y persons subject to workman's compensa- tion laws of California." i The apc nt must call-for all required inspections. Complete drawing on reverse side. Signed Title- itle �.� �� /L! Date: O EPARTMENT USE ONLY Application Accepted by DateIML� a r, Pit or Grout Inspection by Date Final Inspection by Date _ Additional Comments: ❑ tk 466-6781 ❑ Lodi 369-3621 L7 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 , FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVER BY DATE I'i RMIT NO. H. INFO -1c)_1 H +.EHi3-24(itEV.iiHS) v� �O1 (F\��/ EW t4-26 i �J CAJ�.i/•. 4