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.r i c s_ APPLICATION FOR PERMIT FFF��/// SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA C T lephohe (209) 466-6781 I PERMIT E IeRES 1 YEAR FROM DATE ISSUED hh ) (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 City °e\ �W Lot Size Pm t Owner's Name`�'\Jl . -Wtifl^AN� Address s.1 � , �J z � Phone `1 f Contractor s-� Address ` E License No. Phone TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ a ."_=-RUMP.I1�T ❑� C� SYSTEM REPAIR DISTANCE TO NEARE3T�SEPTIC T-A2NKWER ON ESSP FLD. PfiOP. LifCE ' 1 FOUNDATION AGRICULTURE WELL THER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE AREA CO CTION SPECIFICATIONS "❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing 1 ❑ Domestic/Private ❑ Gravel Pack ❑ Trac T e of Casing Specifications t f Public I� Oth elta Depth of Grout Seal Type of Grout _ I I Irrigation �..A prox. De I I Eastern rface Seal Installed by _ Repair Work Done ❑ Type of P M.P. State ork Done W Well Destruction 0 Well Di eter Sealing Material Itop 501 i Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW NSTALLATION .1 f IR/ADDITION i I DESTRUCTION o septic system permitted if public sewer is r `� vailable within 200 feet.) Installation will serve: Residen e_ Commer6 1 t r Number of living units: Number of bedrooms Character of soil to a depth of feet: Water table depth I� SEPTIC TANK ❑ Ty e/ fg No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ( n Distance to nearest: Well Foundation Property Line U LEACHING LINE ❑ No. & Length of lines Total length/size - FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS 0 Distance to nearest Foundation Property Line {d DISPOSAL PONDS ❑ ` w I I hereby certify that I have prepared this applicatih� a [h work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local hl 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[Wanner 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 required ins ctions. Complete drawing on reverse side. �( O Signed X V Title: CM, �. � "!-��Tf Date: F9 1~ '`� 4 ` R DEPARTMENT USE ONLY Application Accepted by Date Area t Pit or Grout Inspection by .,Date Final Inspection byDate Additional Comments: E_ l S 1 13 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 y Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Cz/c/ r s INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT"NO. ft • EM 13-24 1REV.t 145 EH 14-2e ✓ �f U