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li APPLICATION FOR PERMIT it SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE„ STOCKTON, CA Telephohe (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) •tT;ti Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work heroin-described.'Thtis application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and theflules and Regulations of the San Joaquin Local Health District. Job Address 6 1Y 9 LuCity Lot Size PM l3Owner's Name _R!MY1_N Address u/ Phone Contractor E. LJ a `y1 &Address I4 2/ 41 VE [Zk N License No. %39/04 Phone 3Z 7 /ZQ TYPE O W /PUMP: NEW(>VELL ❑ WELL REPLACEMENT ❑ DESTRUCTION.1z PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE.TO NEAREST: SEPTIC,TANK. _SEWER LINES,- DISPOSAL FLD. �^_ �;Pf!OP. LINE � y FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ 'Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout I i Irrigation !_Approx. Depth I i Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Well Diameter Sealing Material (top 501 f Depth / Filler Material (Below 501 4S TYPE OF SEPTIC WORK: NEW INSTALLATION I'i REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is ` r a 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 0 jiType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ :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 SEEPAGE PITS I 1 Depth Size Number t` _SUMPS — ,Ll.t Distance to nearest: Well -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: " 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 Californi .' N The applicant mus a required i cti omplete drawing on reverse s' �a Signed X _ Date: r// &7 FOR DEPARTMENT USE ONLY ' Application Accepted by Date 5- 19- 2� Area 1 Pit or Grout Inspection b Date Final Inspection by Date !i � sfb f43 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 a :, Applicant - Return all copies to: EpvirorVnental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r NFO AMOUNT DUE MOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. a EH 13-24(REV.1/a to � EH 14-261 ti iIi 1