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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � e .J",�), �,. t (Complete in Triplicate) INko& G 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.' iJ 1' Job Address 1744, ll F.AlAg�471L,-_ CitySZo P—i Lot Size la PM ner's Name �/Ld�. #� C F Address 1tl ,Phone Ow. a W t Contractor Address License Na. Phone r TYPE 0 ELL/PUMP: NEW)WELL ❑ WELL REPLACEMENT ❑ „�DESTRUCTION,❑-„ ,.r...�,«..-� PUMP INSTALLATION.p SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDA AGRICULTURE WELL OTHER W PITS/SUMPS INTENDED USE TYPE OF-WELL PRO EA CONSTRUCTION SP CATIONS ” ❑ Industrial b Open Bottom Manteca of W cavation Dia. of Well Casing %Q Domestic/Private ❑ gavel Pack yp ❑ Tracy sing Specifications z ❑ Other IF7Del Depth of Grout Type of Grout y V ❑ Irrigation �pprox. Depth Eastern Surface Seal Installed by Repair Work Done%*E1w*�Type of Pu H.P. State Work Done ' Well Destruction ❑ We ameterr Sealing Material (top 541 nth _ Filler Material (Below 501 TYPE OF SEPTIC-WORK: f+IEW;INSTALLATION ❑*REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) 4 # installation will serve: ResidericCommcal L Other Number of living units: �Number of bed ooms . ... Character of soil to a depth of 3 feet: F � Water tabledepth SEPTIC TANK Type/Mfg - Capacity No. Compartments r PKG. TREATMENT PLT. ❑ ° Method of Disposal Distance to nearest:/" Well Foundation Property Line ,✓ r LEACHING LINE ❑ No. & Length of lines Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line t r SEEPAGE PITS ❑ Depth Size Number : SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ v 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 t 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 all re 1.11i d inspect' ns. Complete drawing on reverse side. Signed XTitle: Dater ( f/ � i FOR DEPARTMENT USE ONLY 3 _ ,m Application Accepted by - •�* Date ` -1� Area U i ¢ Pit or Grout Inspection Date/ Final Inspection by Date- / Additional Commerl, �� ❑ Stk 466-6781 ❑ Lodi 369 3621 Manteca 823464 ❑ Tracy 8354085 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERmi-r-NO. INFO CCAVP 4 _ " + EH 13-24{REV.t i a 57 + um'� • ', -f 9/—/j 2 EH 14-29 i