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1M APPLICATION FOR PERMIT _ USAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 \T"� PERMIT EXPIRES 1-YEAR FROM DATE ISSUED Iv"Q�-A (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. Job Address �NC Lot Si Cit ,-10/f 6 „ City ze_ !f 0— PM Owner's Name i1Jrp_�� 77 /\ pr� '�• Address '�(O /rl�Gt �J� Phone `O(6! 2- Contractor � L Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._— PROP. LINE (n FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS "1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dra. of Well Excavation ❑ Domestic/Private Ll Gravel Pack ❑ Tracy T pia. of Well Casing ype of Casing Specifications M Public ❑ Other {l Delta Depth of Grout Seal I I IrrigationType of Grout --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H .p - state ork Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filier Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION 1 1 DESTRUCTION r (No septic system permitted i( public sewer is Installation will serve: Residencer vailable within 200 feet.) Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 fee SEPTIC TANKWater table depth Type/M Capacity No. Compartments PKG. TREATMENT PLT, El Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No, & Length of lines FILTER BED ❑ Distance to nearest: Well Total length/size Foundation Property Line SEEPAGE PITS I 1 Depth Size SUMPSNumber CI Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line 1 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." 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, tion laws of California." !shall employ persons subject to workman's compensa The applicant t cal for I required inspectlo s. Complete drawing on reverse side, Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date C1" Area Pit or Grout Inspection Date Final Inspection by Date Additional Comment 92 ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 Applicant - urn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO ry H RECEIVED BY DATE PERMIT*NO. { EH 14-28EM 13-24 fFEV.tirs5) �