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APPLICATION FOR PERMIT �✓ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED r (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 I Local Health District. 4w Job Address J 0 City Lot Size PM Owner's Namet�f4dtftess - '7'Q hone ContraclaLf2d�ddress �� U rl�UTZ'(Jr License No. /�2 p Phon 7 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 FOUNDATION AGRICULTURE WELL OTHER WEL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT[ CIFICATIONS ❑ Industrial `❑ Open Bottom"'"" '"❑ Manteca— — Dia ell Excavation Dia. of Well Casing L7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing I Specifications 1`7 Public ❑ Other Cl pelt Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I astern Surface Seal Installed by _ Repair Work Done LI Type of Pump H.P. " qtr ' I State Work Done Well Destruction ❑ Well Diameter SZ n; Material (top 50') _fi Depth 1 .a fO Filler,Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION IJ' REPAIRIADDITION i I DESTRUCTION (No septic system permitted if public sewer is 110, —' available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms Character of soil fo ade th of I feet """ """��'"'+'"'F P Water table depth SEPTIC TANK 1-1,, ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT?O Method of Disposal'-' Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Notal length/size a FILTER BED ❑ Distance#nearest: Well I Foundation * Property Line SEEPAGE PITS I I Depth Size Number ' f SUMPS ❑ Distance to nearest: Well Foundation Property Line - I DISPOSAL PON 3S ❑ .1 - 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.,,.,I 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 must call for all required inspections. Complete drawing on reverse side. +l Signed XFry Title: .- Dais: FOR DEPARTMENT USE ONLY Application Accepted by rDate r r Area I Pit or Grout Inspection by p Final InspE101ft by Dat l Additional Comments: k•C• 1A)P.S f7 Bp365 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Man eco 823-7104 ❑ Tracy 835-6385 ' .�p �, E Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 41 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By f DATE PERMIT-NO. + EH 13-24{REV.i/H sl EH 1426 + 4