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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. WAZELTON AVE., STOCKTON, CA t L, Telephone (209) 466-6781 �1 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. Q I Job Address / r�s z 07,4 City Lot Size PM Owner's Name T/� -{�/�/rf�cyw ��ress� CP �+ Phone G\ Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ LL REPLACE T ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM PAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE LL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of ell Excavation Dia. of Well Casing ❑ Domestic/Private © Gravel Pack Ll Tracy Type of C Ing Specifications I1 Public ❑ Other ❑ Delta Depth of G\ulSeal Type of GroutI I Irrigation � Approx. Depth I I Eastern Surface Seled by _ Repair Work Done ❑ Type of Pump P. State Work Done Well Destruction ❑ Well Diameter Sealing Material )top 501 Depth Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I 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 Character of soil to a depth of 3 feet,I Water table depth i SEPTIC TANK ❑ Type/Mfg, Capacity No. Compartments PKG. TREATMENT PLT. C_l I 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 I SEEPAGE PITS 11 Depth Size Number i SUMPS 0 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 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 applica t t_call for all r quired inspections. Complete drawing on reverse side. Signe Title: Date: '�� k FO DEPARTMENT USE ONLY Application Accepted by Com`^ l 9�vnti_ �� Data �� Area Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: 4 ✓�✓+ r' roc s e ✓x� vs ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ anteca 1123-7f04 ❑ Tracy 835-6385 6 �rivw r f ?,is a.e 11 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEEOINT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO r / /CASH ® / t.EH 43-24 tpEV.t/145; 3 EH 14-28 V- / l7+