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APPLICATION FOR PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA �qJ Telephone (209) 456-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUEDL - I . (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. t KJob Address /�� I S 4-1 cit Size PM y\ Lac] ��Id Owner's Name re F - y� ` Phone Q w - - Contractor 6�Address, f • .License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ = PUMP INSTALLATION"❑' SYSTEM-REPAIR-❑ �OTHER.M { DISTANCE TO NEAREST:SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF L PROBLEM AREA CONST PECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Type of Casing Specifications FI Public F1 Other Delta Depth of Grout Seal Type of Grout I I Irrigation _:.Approx. th [ I.Eastarn ce Seal Installed by Repair Work Done ❑ Type of mp H.P. State Work Done _ r Well Destruction ❑ We Diameter Sealing Material (top 50') ! Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW.INSTALLATION Ia REPAIR/ADDITION f I DESTRUCTION o septic system permitted if public sewer is 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 �y SEPTIC TANK ❑ Type/Mfg ` Capacity No. Compartments f PKG. TREATMENT PLT. Cl, Method of Disposal U t Distance to rER.tt. MIT_ -FX and t Property Line LEACHING LINE .❑I,,,,,No. & Lengt a title may have expired RhOUt Total length/size FILTER BED, ❑ Distance tiw4r!�sbeingvaumpWted uprjmpeded Property Line SEEPAGE PITS I I- DepthIzeIii ,6 'L Divisional Health Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r 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, an rules and regulations of the San Joaquin Local Health Driltrict. Home owner or licensed agent's signature certifies the fallowing: "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 is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicantrr s{rcall for all required inspe�ti . Complete drawing on reverse side. Signed ZilTitle: 0 1 LA."�__..-_--. Date: MEN�USE NLY ' Application Accepted byDate Area 1. Pit or Grout Inspection by Date Final Inspection by Date 3 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 t Applicant- Return all copies to: Environmental Health Per 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 955201 FEE INFO AMOUNT DUE AMOUNT y�REMITTED CK RECEIVED BY fDATE PERMIT•NJO. -EH 13-24IREV. 57 EH 14-26 1