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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTO�•N, CA Telephone (209) 466-6781 1'�= PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I 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 t 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 w Local Health District. F ^ 1211 y WI-T Job Address ��"'��{[� S�T'it1�►'T�O�,,'Ll City Lot Size )C !"1 PM Owner's Name ELW%e IV\ .= L� LV'IA`ddress I�r�tit-3 Phone %8%164.W1 { f ! Contractor r Address I License No. i Phone TYPE OF WELL/PUMP: NEW WELL`In WELL REPLACE NT ❑ DESTRUCTION ❑ PUMP IN STA LLATIOW:❑ SY9TEZME PAIR. OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER L ES 0 DISP SAL FLD, PROP. LINE FOUNDATION AGRICULTU A ELL OTHER WELL PITS/SUMPS ` #INTENDED USE TYPE OF WEYREAREA N RUCTION SPECIFICATIONS industrial ❑ Open BottomDia. of II Excavation ; 3 Dia. of Weil Casing ❑ Domestic/Private ❑ Gravel PackType of-Cas _f "`Specifications ❑ Public n OtherDepth of Grout eal Type of Grout M.I I Irrigation _.-Approx. DSurface Seal Insta d by `Repair Work Done ❑ Type of Pump .P- tate'Woik Done r— Well Destruction ❑ Well Diameterealing Material (top 501 I Depthiller Material IBelow 501w C. TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUC:TIONX INo septic system permitted if public sewer is available within'200 feet.I Installation will serve: Residence Commercial T Other Nurt bev 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. F] I Method of Disposal t r Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line j SEEPAGE PITS I I Depth Size Number +I SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i 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 i 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." I The applicant ust call for all,required inspections.C o p ete drawing on reverse side. j }� a I Signed 9C E Date: OR EPA ENT USE ONLY Qt Application Accepted by Date 0"7, V Area Pit or Grout Inspection by Date Final Inspection by Date a Additional Comments: C7 Stk 466-6781 ❑ Ifodi 369-3621 ❑ Manteca a23-7104 fl Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEINFO A OUNT DUE AMOUNT REMITTED - CASH RECEIVED BYFDAITE PERMIT NO. � r EH 13-2�IREV.r/n 5Y �QV � EH t4-2[l