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APPLICATION FOR PERMIT �- SAN JOACIUIN LOCAL HEALTH DISTRICT z _J 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209} 466--07811 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 [ 7 'F D 1 e>r r� L rQ City a 611 Lot Size Vz'f PM Owner's Name 7i)�as-.'._- _ Address LL� 051�1'I` a ' t� Phonek 76)— —0 Contractor ( � Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPT NK SEWER LINES DISPOSAL FLD. PROP, LINE \ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBL A CONSTRUCTION [CATIONS ❑ Industrial ❑ Open Bottom 0 Manteca a Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casi Specifications [`l Public ❑ Other elta Depth of Grout Seal Type of Grout _. I I Irrigation __Appro pth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type ump H,P. State Work Done Well Destruction ❑ Wel 'am-ter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION 1 1 DESTRUCTION ViNo septic system permitted it public sewer is available 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 1 I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property tine 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 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 at in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of Cali rnia." The applic t ust c r II uire inspections. Complete drawing on reverse side. Signed 17 Title: bate. FOR DEPARTMENT USE ONLY Application Accepted byDate _ /� raa Pit or Grout Inspection b Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED I CK 0 CASH RECEIVED BY DATE PERMIT'NO. EH 13-241REV.1/A5) _ 5 'H 14-2e �, '�— C�LG