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f APPLICATION FOR PERMIT P - SAN JOAQUIN LOCAL HEALTH DISTRICT 1501 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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/of install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin /Local Health District. Y Job Address ,2 ' re / 'rr r City i"' Lot Size PM + yes cr rL�s ro [ !n 4 r A/C Y Owner's Name D rz�k-6 r9�a3 Address _L 7Q 6 -�/_"` ��_� r Phorr�gl� co�y aTlo Contractor c5,P-� + Address r 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 FOUN AGRICULTURE WELL OTHER PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR TRU ECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Exc Dia. of Well Casing ❑ Domestic/Private C] Gravel Pack ❑ Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation —:-Ap Depth l I Eastern Surface Seal Installed by _ T - Repair Work Done ❑ Typj of Pump H.P. State Work Done Well Destruction ❑ ell Diameter Sealing Material (top 501 epth Filler Material {Below 501- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i i DESTRUCTION (No septic system permitted it public sewer is �. or vailable within 200 feet.) ` 1 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 1 "w 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 r SEEPAGE PITS l I Depth Size _ Number SUMPS Ll._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 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 m t call for all required i spections. Complete drawing on reverse side. Signed X Title: Date: h es 4976 FOR DEPARTMENT USE ONLY �L Application Accepted by _ Date _ Area 0 Pit or Grout Inspection y DaM `J Final Inspection by '"""� Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369.3621 Ib Manteca 823-71164 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f FEE INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'N0. +.EH 124(RFV.1/8 a)4-