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F APPLICATION FOR PERMIT ; SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) �O 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 i Local Health District. Job Address 02 40 Ei City Lot Size PM Owner's NameDz4x� Address ��2 Phone ` Contractor awk 4mwk Address * License No, F_00 Phone TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES- DISPOSAL FED. PROP. LINE y FOUNDATION. AGRICULTURE WELL PITS/SUMPS INTENDED USE TYPE OF,WELL— STRUCTION-SPECIFICATIONS 1 EI Industrial ❑ Open,F3oti Manteca fDia. of Well Excavation ` Oia. of Well Casing t ❑ Domestic/Private f e Pack fe- ❑ Tracy Type of Casing Specifications i'1 Public ❑ Other tL ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx.—Depth —I)Eastern ' Surface Seal Installed by - Repair Work Done ❑ Type of Pump j H.P. State Work Done_ Well Destruction ❑ Well Diameter,,R,� `- Sealing Material Itop 50 — . Depth `' Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION f a REPAIR/ADDITION {.I DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.) 1 F Installation will serve: Residence Commercial_ Other Number of living units: Number of bedroorn5' Character of soil to a depth of 3 feet: Water table depth RtSEPTIC TANK Type/Mfg Capacity - No. Compartments PKG\TREATMENT PLT. d f Method of Disposal DistancProperty.Line e to nearest:: Well Foundation _LEACHING LINE ❑ No. & Length of lines may- c Total length/size FILTER BED ❑ Distance to nearest: Well `'iFoundation Property Line r SEEPAGE PITS i I Depth Size Number f SUMPS D Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ I hereby certify that I have prepared this application a6d that'tFie 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 applicant st call for all re wired i pections. Complete drawing on reverse side. ^� Signed Date: FOR DEPARTMENT USE ONLY Q Application Accepted by w t , Date ��V� Area Pit or Grout Inspection by Date Final Inspection by Dat Additional Comments: �U ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REmiTTED CK H RECEIVED BY DATE PERMIT'NO. s INFO I +.EH 13-24 IflEY.t i K5) ;' EH 1426 - - -