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��Fdlr� APPLICATION FOR PERMIT `} (o2:vv +VoaA 5 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. - r\Job Address M City Lot Size PM ofOwner's Name •I � Q e � !\ , Address 2-L VPhone e<lcontractor �_f1J�S��__ Addres _ License N Phone TYPE OF WELL/PUMP: NEIN WELL ❑ ELL REPLACE ENT DESTRUCTION 1-1PUMP INSTALLATION LJ SYSTEM EPAIR ❑ OTHER C1DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTUR W LL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO TRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca a. o Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype of asing Specifications y ! 6 ❑ Public F1 Other ❑ Delta Depth of rout Seal Type of Grout__. I I IrrigationApprox. Depth I Eastern Surface SNInstalled by _ Repair Work Done ❑ Type of Pump I H. State Work Done _ Well Destruction ❑ Well Diameter.l ealing Material Itop 50') A Depth Filler Material (Below 50'1 — TYPE OF SEPTIC WORK: NEW INSTALLATION I.) R PAIRIADDITION E I DESTRUCTION I I (No septic system permitted if public sewer is (n F available within 200 feet.) �/ f Installation will serve: Residence_' Commercial_ Other' Number of living units: � Number of bedrookQs f t, Character of soil to a depth of 3 feet: Water table depth rEPTIC TANK ❑ Type/Mfg'r � Capacity) j!'00 No. Compartments �—"� PKG. TREATMENT PLT. 13L/ r Method of Disposal Distance to'nearest: Well �,� -- Foundation Property Line L CHING LINE C�o. & Length of lines op Total length/sizeER BED ❑ Distance toynearest: Well 1 Foundatio Property Line PAGE PITS I ! e Size NumberMPS ❑ i fence tonearest: Well Foundation — Property Line POSAL PONDS :I reby certify that I have prepared his application and that the work will be done in accordance with San Joaquin county ordinances, state laws, ands and regulations of the San Joaquin Local Health District. 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 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 it.issued, I shall employ persons subject to workman's compensa- tion laws of California." i The applicant mus for allre uu in ons. Complete drawing on reverse side. + f Signed �cL/:ri Title: —---'S C.9 �Q-1'P . - Date: OR DEPARTMENT USE ONLY Z Application Accepted by Date 3- _ Area Pit or Grout Inspection by I Dat Fnal Inspection by _ Dat Additional Comments: i I ❑ Stk 466-6781 ❑ Lodi 3621 Manteca -7104 ❑ Tracy 835-M85- Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 INFO AMOUNT DUE I AMOUNT REMITTED CASH RECEIVED 9Y DATE PERMIT-NO. k i +-EH 13-24(REV.i i8 sl (9.0) I 70 y 133 yd S7 EH 1428