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APPLICATION FOR PERMIT r ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ll1 f (Complete in Triplicate) .vt h j U rV%A r Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work he described. This appliLatiofi 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 `-' a � City of Size C PM Owner's Name Address Contractor. �rlt_,Triu eetzr Address - .,&L444_A_� License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 9 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE AREST:.SEPTIC TANK SEWER LINES DISPOSAL FLD. .PR UNDATION AGRICULTURE WELL 0TH PITS/SUMPS INTENDED USE TYPE OF OBLEM AREA TION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ec ia. of Well Excavation Dia. of Well Casing fJ Domestic/Private ❑ ack ❑ Tracy Type of as Specifications f1 Public ❑ Other i-1 Delta Depth of Grout Seal T pe of Grout I I Irrigatio --Approx. Depth I 1 Eastern Surface Seal Installed by Repair Wqrk Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') { Depth Filler Material (Below 501 i. TYPE OF SEPTIC WORK: NEW INSTALLATION 11' REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence� Commercial— Other r Number of living units _ - Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. El Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well . Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS "0 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. 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 E 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 applicant must call for all r quired inspections. Complete drawing-on reverse side. Signed Title: . t� �- �j �p Date: __ FOR DEPA�RTIMENT USE ONLY Application Accepted by f Date_ r�t Area ¢ Pit or Grout Inspection Q /Date �J Final Inspection by' Date 1.11 Additional Comments: t� / CJ rb / �^ �O 7 c� �5 Lv f x 1 ❑ Stk 466-6781 ❑ Lodi 369-362f ❑ Man ca 823-71 ❑ Tracy-/835-6385 c s Applicant - Return all copies to: Environmental Health Per it/services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., C � � w 7 eel FEE INFO AMOUNT DUE AMOUNT REMITTED C&+1 RECEIVED BY DATE PERMIT'NO. +,EH 13.24 1REy.;i N 5) 37�_ V+rCCCAAAI��- EH 14.26