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APPLICATION FOR PERMIT _ �d SAN JOAQUIN LOCAL HEALTH DISTRICT v 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 �V PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) V 7 A n,, , 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 City Lot Size 7KX3(0 3(0 PM Owner's Name Address,,2/ 4fC&IVPhone S 1,(-q 0,1@ AJ -J*:�,-_3 7 0 Contractor 5�ce, Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES, DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE7OpenBottom L PROBLEM AREA CONSTRUCTION SPEC ❑ Industrial ca Di xcavation Dia. of Well Casing ❑ Domestic/Private ❑ e of Casing Specifications f'1 Public ❑ Delta Depth of eaI Type of GroutI I Irrigation pth I I Eastern Surface Seal Installed Repair Work Done Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is vailable 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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ 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 ❑ 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 Di?;trict. 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 Calif a." The applicant 'ust c 1 for all re r inspecti to drawing on reverse side. Signed X Title: ��/L/tf�� C+� Date: —/ 7— C.".41 FOR DEPARTMENT USE ONLY / Application cce ed by Date ` _ -2 Area Pit or Grout Inspecti b r Date Final Inspection by ` �t ��.�f` Date `J Additional Cgmments: 3� �U � �-71,5"3 a ��CGfr /p, /��1or/r�i�L ❑ Stk 466-6781 O Lodi 369-3621 El Manteca'823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 16001 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ® W N L,v+- S U L d 0 161 �'�c, tL LJ c.3 t�✓�© � rf! !.�1 l �L di O INFO FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. D �j Q1 � +.EH13-24IREV.t/H5) �. --7- ��\� -- / ;�.r � I ' �� 1 u EH 14-26