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i� _ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT . HAZEL T ON AVE., STOCKTON, CA 1601 E Telephone (209) 466-6781 , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �l1 (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 -2,6 City r410 Lot Size PM Owner's Name _EF Lia LI-0 41 1-71-"1 e.Z Address V 0 Phone C/ r Al Contractor Address 1 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 - DESTRUCTION ❑ PUMP INSTALLATION ❑ 4 SYSTEM REPAIR ❑" t �} -i OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEW�LlS DISPOSAL FLD." PROP. LINE FOUNDATION AGRIE WELL 0TH PITS/SUMPS INTENDED USE ,TYPE ><_ ��" LENt AREA "" C T SPECIFICATIONS"' - 4 ❑ Industrial ❑ Opennteca o ell Excavation Dia. of Well Casing , ❑ Domestic/Private ❑ Gravecy Type of C g Specifications D ❑ Public ❑ OtherDepth of Grou I sal Type of Grout ❑ Irrigation �A11 pstern Surface Seal Insta, d by ! — W Repair Work Done ❑ Type of H.P. F State Work Done Well Destruction ❑ Well DiaSealing Material (top 50'1 Depth __ _Filler Material (Below 501 l TYPE OF SEPTIC WORK: NEIN INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (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 i Character of soil to a depth of 3 feet Water table depfh SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑%r . G j Method of Disposal rDistance�to nearest: ._WellFoundation-" -Prop'erty -Line- _ ' r i � € LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ ! Distance to nearest: Well Foundation Property Line ;t SEEPAGE PITS Depths Size Number SUMPS ❑' Distance to nearest: Well Foundation PropertyLine 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,fovwhich this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California.',.Contractbr's hiring or sub-contracting signature t 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- do alifomia." e applica t t call for all required 1G . Complete drawing on reverse side. t Signed Title- `^' ""`_ Date: [}� FOR DEPARTMENT USE ONLY'` Application Accepted by Date Date �" Area e. ! Pit or Grout Inspection � �"�--"" Final Inspection by_.�' Date ! " ' Additional Comments: n ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 86-7104 ❑ Tracy 8354i385 k Applicant - Return all copies to: Environmental Health Permit/Servioes,1601 E. Hazelton Ave., P.O."Boz 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED,-BY DATE PERMIT`NO." INFO �E--- + EH 13-241REV.'1/e 57a 4 EH 14-28 I