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APPLICATION FOR PERMIT V`max C a �+ l�q SAN JOAQUIN LOCAL HEALTH DISTRICT x 1601 E. HAZEL T ON AVE' STOCKTON, CA S 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. 1882 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. yfi. Job Address aE ►=.tom �b s Ci !��'. ."l d Lot Sizes �¢ pM Owner's Na _Y Address b f P - Z� A /� hone Contractor .S!T .1- Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK . EWER LINES ISPOSAL FLD. PROP. LINE FOUNDATION AG ULTURE WELL �' OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR CONST ION SPECIFICATIONS ❑ Industrial '❑ Open Bottom ❑ Manteca of Wel! Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Grave! Pack ❑ Tracy Type f Casing Specifications ❑ Public ❑ Other Q Delta JDepth.o.. rout'Seiil Type of Grout (� Irrigation _._Approx. Depth ❑ ern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done r Well Destruction ❑ Wall Diameter ` Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_—Other- —-•- _ --�_ __ ! Number of living units: Number of bedrooms r ^ Character of soil to a depth of 3 feet:; r Water table depth r� SEPTIC TANK ❑ Type/Mfg ) Capacity No. Compartments `+ PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well r Foundation- Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance toinaarest: Well f Foundation Property Line {� i SEEPAGE PITS ❑ Depth Size Number ' SUMPS ❑ Distance to nearest: Well + Foundation � � Property Line DISPOSAL PONDS ❑ 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 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 laws of-California.'-Contractor's hiring or sub-contracting signature f111 certifies thefollowing:`"fceitify that in the performance of the work for which this permit is issued,I shall employ persons subiect to workman's compensa- tion laws of California." T plicant a for all required inspecti Complete draw ng nn reverse side. Signed Title: r t Date: _ I FOR DEPARTMENT USE ONLY Application Accepted by Date —2 8 Area t lo Pit or Grout Inspection}by # Date Final Inspection by Date Additional Comments. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-BM Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 -FEEINFO y AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + eH13-24(REV. 5, on ®LAS EH 14-26 31.Y U F