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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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. Job Address `�' IV City Lot Size 7 4 PM Owner's Name r Address J N Phone —0 2 7 Contractor .// iddress 1� IVI / f Q IV _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 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED SE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing ❑ Domestic/Private ❑ r ❑ Tracy T ng Specifications ❑ Public ❑ Other Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Dept astern u Installed by Repair Work Done ❑ Type of P H.P. Well Destruction ❑ iameter Sealing Material (top 50') Depth Filler Material (Belof 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Wr DESTRUC ION (No septic system permitted if public sewer is � .�,� , 44 Z� available within 200 feet.! Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms._._..,_w Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK C1Type/Mfg P*iko Capacity No. Compartments PKG. TREATMENT PLT. C1 ' Y Method of Disposal _._ Distance to nearest: Well Z O Foundation /t/ Property Line __. LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well JM Foundation_? 17) Property Line SEEPAGE PITS El Depth Size Number SUMPS ❑ Distance to nearest: Well/l ) FoundationC7 Property Line 0 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: "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 t require inspections. Complete drawing on reverse side. )) ` Signed Title: Date: FOR DEPARTMENT USE ONLY b Application Accepted by Date Z 5 o Area ` Pit r Grout Inspection by Date 3`g Final Inspection by Date -j 3� Additional Comments:Prima r 1-" s�•w Pr z. yS L.t.,,� a 5 �,�y f�ryy�� p, S{ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M °- Applicant- Return all copies to: Environmental Health Permit/Services 16D1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK ASH RECEIVED BY DATE PERMIT'NO. + EH13.241REV.t/e51 / O COV �1 F1t1/'1 —1b—Y'7 ?7. 97 EH 1428 �� If 1'� ( VI/ ! r