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APPLICATION FOR PERM0 IT v SAN JOAQUIN LOCAL HEALTH DISTRICT 43 C 1601 E. FEAZELTON AVE., STOCKTOIV, CA at Telephone 1209) 8a- r !! ✓� P— R PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l l (Complete Irt 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.. ,�/ I Job Address ! /V�. Or iye /4 Ye- City 5r4CV'VAI Lot Size PM Owner's Name /1if r�C C r — Address Z�3 r Pe'&P 5i s 7eCK LOA,- Phon�Z�� Contractof�� Address License No. _ Phone YPE 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 WEL UMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU PECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mantecaof Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Graver Pack ❑ Tr Type of Casing Specifications ❑ Public l=1 Other Delta Depth of Grout Seal Type of Grout--- I rout _I I Irrigation T_A Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ e of Pump H.P, State Work Done Well Destructio Well Diameter Sealing Material (top 50'1 �. Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial T 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 1" 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 Depth Size Number SUMPS hI 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 California." The applicant sttc 11 for all required inspections. Complete drawing on reverse side. Signed X_ , ,G ;!�!/Z! Title: C Y Date: FOR DEPARTMENT USE ONLY /1 Application Accepted by Date �— , Area V O Pit or Grout Inspect' n ✓�, ,/ /� D Final Inspection by / Date Additional Comments: l cif!r,o moi" � V (1 (1 ❑ Stk 466-6781 © Lodi 369-3621 ❑ Manteca 1123-7104 Cl Tracy 835-6385 PC, 0)e-, { ty u w 0 � Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r uer0 z INFOEEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. r.EH13-24(REV.i i H 51 EH t4-2e