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APPLICATION FOR PERMIT x- SAN 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA6� ��,C,G1'�✓�'C�� I Telephone {209) 466-6781 �r ��/ 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. r Job Address S �4'/lLFi yr P. Y City r Lot Size PM �' �01 Owner's,Name + u Address ( rAa7iip>r Phone ¢ Contractor a& l� Address 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 FOUNDATION AGRICULTURLL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca -, of ell Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Typ of asing Specifications r I`I Public Cl Other ` ❑ Delta Depth f Grout Seal Type of Grout I I Irrigation �,.Aµprox. Depth l I Eastern Surface eal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Mat riaE (top 50') Depth aterial (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALyATION I I R P IR/AD TION�IDESTRUCTION I I (No septic system permitted if public sewer is 1)/ available within 200 feet.) Installation will serve: Residence I' Commerci herj` g 'Number of bedroom _}--- . _�..;._ .--,---..,t._.-.....WateT-table-de - Number of living units: Character of•soihto"a depth-of B feet:-- • -r-•�- pth-i---�+�-,- ' . SEPTIC TANK Type/Mfg 4 LJ � Capacity_ D� _ _ . __.._ Method ofa0i Disposal - PKG. TREATMENT PLT. ❑ i ! ' Dis6nce',to,nearest"; ell- " -470 foundationroperty"Cine`>�dfa'"� 4 LEACHING LINE - ..No. & Le _- ...-.. _ .... - ngth of lines © Total iength/size d 6 i > J - oundatior>? "Property Lme ' FILTER BED ❑ Distance7ro'nearest '•"Well F SEEPAGE PIT'S I I Depth it i Size Number SUMPS Ley Distance;toj nearest,-. Well Foundation-" Property°Line - - DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county oidinances, state laws, and rules.and regulations of'the San Joaquin Local Health District-.-- - ..i.. . - r . -' . _. .. _ _._ �__ _ ..._ _. _.t-. _ — . _ 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 shalt 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." _y The applicant must call for all required in ctions. Complete drawing on reverse side. Signed X_._r7-. Q.ir/"'zC7 c/ C�zz Tit —_�[.0�N 4✓� .Date: � ,� JJ FOR DEPARTMENT USE ONLY Application Accepted by � ,-' Date _ Area ~ 4. Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑.Stk 466-6781 " O Lodi 369-362"1 ❑ Manteca 823-7104 -- ❑"Tracy-835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 j FEEA�MOUNTIDUE �� AMOUNT'REMITTED K "'"RECEIVED BY DATE PERMIT NO'. INFO C H x " +.EH1 3-244REV.Tinel "' 'f EH 14-26 _ ._. .. __..,0