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I~ �d � 741 C_- 4�--J a-*,of APPLICATION FOR PERMIT IL ,`. �✓as w" SAN JOAQUIN LOCAL HEALTH DISTRICT b,,ck-11'f 4,, 4.e-f` 1601 E. HAZELTON AVE., STOCKTON, CA 1� 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. 6 Sff�rr' L Job Address !S.? �i_ � City 5'f2Gh.fOI►/ Lot Size 30 X !al)/ PM -7--4�esSrr 132 w • 'DG�Q ✓�.a cc.r „G Owner's Name Ji-ii Liq i . l'%51 Address ilat=tEVTK= A Phone c l,�1 Contractor--S�-(_J Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION GRICULTURE WELL OTH LL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM CONSTRUCT PECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Di ell Excavation Dia. of Well Casing _ ❑ Domestic/Private ❑ Gravel Pack ❑ Trac of Casing Tracy g Specifications N ❑ Public ❑ Other ❑ D Dept f Grout Seal Type of Grout ❑ Irrigation --Approx. Dept Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pu H.P. State Work Done Well Destruction ❑ Well D meter Sealing Material /top 50'1 Depth Filler Material /Below 50'i � 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 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 ❑ 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 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." Thea licant muA call for all required inspect' ns. Complete drawing on reverse`side. e Signed Title: u w ' Date: .3 20 '$7 . — r FOR DEPARTMENT USE ONLY �] �^ Application Accepted by Date 5"7 Are��arr Pit or Grout Inspection by Date Final Inspection by Otak, rkL"*- lei* Date Additional Comments: c Cy ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835M655 ' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 v FEE INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY /DATE PERMIT'NO. + EH 1428(REV.v/e 51 -1� - 00 0c,