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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT No I"-y 1 �V OXh 1601 E. HAZEL T ON 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. //' 5', ,J Job Address (g Z6 e�o 5r City CO2 16/Lot Size IX13rz PM Owner's Name ,C/ �®� 40, N�/gTK11 Address C.& S, UpCa rte, Phone 6 0 Contractor-- i6 F Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ��7 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P LINE SFA DATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL BLEM AREA CONSTRUCTION SPECIE NS ❑ Industrial ❑ Open Bottom ❑ Manteca ofWell anon Dia. of Well Casing El Domestic/Private 11 Gravel Pack ❑ Tracy of a Specifications ❑ Public ❑ Other Depth of Grout Seal Type of Grout ❑ Irrigation . epth ❑ Eastern Surface Sea[ Installed by �\ Repair Work Don Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION, (No septic system permitted if public sewer [s available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation - Property Line SEEPAGE PITS ❑ Depth Size Number, SUMPS ❑ Distance to nearest: Well Foundation - Property Line ' DISPOSAL PONDS ❑ 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."Contractoes 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 m t call for all required inspections. Complete drawing on r erse side. Signed Title: Date: ��SF' — V / FOR DEPARTMENT USE ONLY Application Accepted by Date Area �. . ._ Pit or Grout inspection by Date Final Inspection by ate Additional Comments: ❑ Stk 466-Ml ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO aAMOUNT DU AMOUNT REMITTED EH 14-26 L70/ CK RECEIVED BY DATE PERMIT NO. + E14 3-24 .tia51 cJC7r JJi /v✓ 9�9 ,C� a�� s-�