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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 02 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. 1851 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ' F r 7 � ��/ Ci lyelk-T`'�ot Size 3 PM '.Job Address �1 �' t 4 -7 Owner's Name!- /LJS� Address � ! I 5f•01V Phone Y0 R Contractor ey1,41� /4 ff Address a7 / f � License No. Phone TYf4LQF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION ❑ �- C INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARES TANK SEWER LINES DISPOSAL FLD. PROP. LINE DA AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE '"` TYPE OF WELL TPR REA -"CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of a Specifications 0 Public ❑ Other ❑ Delta Depth.of Grout Seal Type of Grout ❑ Irrigation _ --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done El Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') i Depth i Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 DESTRUCTION APrTNo 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 SEPTIC TANK ❑ Type/Mfg Capacity' No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ] 3 Distance to nearest: Well ;a Foundation Property Line } { LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS v ❑ Depth Size Number f SUMPS i ❑ 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 performani5e of the work for which this permit is issued, I shall not 4 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 appli ant ast call for all re !red inspections. Complete drawing on reverse side. s Signed Title: Date: F DEP LT ENT USE ONLY t a Application Accepted by � � __. DateY2- Area �� fr Pit or Grout Inspection by Date // G Final Inspection by Date IJ ' Additional Comments: �7 a 7 3a 2I I ❑ StO 466-6781 Ll Lodi 369-3621 El Manteca 823-7104 0 Tracy• 835-&385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 nn t /FEE NFD AMOUNT DUE AMOUNT REMITTED RECEIVED BY,, DATE PERMIT'NO. 1 d R . Z II.. + EH 1324 IRiV:-$ ��\ �� 7-S�csU EH 5428 r