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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CAC -7 Telephone (209) 466-6781 _[ J 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 �" o ity N Lot Size Actt_ PM Owner's Name 6M(k Address �/ ir/f/c . I- mks, Phone Y~ 7F1 �9 �. Canlract 1d1 ISG &tl&frSAddress CJ• ��1 1 R'' License No. ,. rJ Phone / �rc _ . WELL/PUMP: r NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ J SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARES IC TANK SEWER LINES DISPOSAL FLD. LINE FOUNDA AGRICULTURE WELL OTHER WELL PITS/SLIMPS INTENDED USE TYPE OF WELL PR AREA CONSTRUCTION SP.15XATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca a. of xcavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy pe o Specifications f7 Public Ll Other ❑ D Depth of Grout Sea , Type of Grout —.-- I I Irrigation _..Approx. D I I Eastern Surface Seal Installed by Repair Work Done ❑ Ty ump H.P. State Work Done Well Destruction ell Diameter Sealing Material Itop 50') Depth Filler Material (Below 50') _ PE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_X Commercial_ Other' Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: ' - Water table depth SEPTIC TANK 0 Type/Mfg � Capacity ~ _ No. Compartments ' PKG. TREATMENT PLT. ❑ f Method of Disposai Distance to nearest: Well-- Foundation Property`Line mow' LEACHING LINE ❑ No. & Length of lines Total length/size. FILTER BED ❑ Dista'nce to nearest: Well Foundation— Property Line SEEPAGE PITS I 1 Depth Size _ Number SUMPS 0 Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ ' I hereby certify that I have prepared this application and that the woek will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. 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 follo 'I certify t at in the-performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of C ornia " The applican must 11 for i eq it coons. Complete drawing on averse side. Signed X Title: / d at � Date: FOR DEPARTMENT USE ONLY I Application Accepted by Date7-e-0Area Pit or Grout Inspectio y Date Final Inspection by Date 72� �U p F Additional Comments: ❑ Stk i 466-6781 ❑ Lodi '369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Silk., CA 95201 FEE IS} � INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIYNO. r +.EH 13-21(REV 41 .t/e 51 [ EH 14-28 J %� —��~