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SAPPLICATION FOR PERMIT SAkj - OA_.UIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE:,.STOCKTON, CA Telephone (209) 466-6781, t 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 madein 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. vs :•; �� c..,. / '' t l• t T Job Address . City Lot Size PM Owner's Name k tps 5 C@o A A' '67 Addres 7Address "41 yS��c� s� Phone Contractor :5 1i' C Address -�/7 el m S "e441-41 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANC 0 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE AGRICULTURE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PRO REA TR TION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gra ack ❑ Tracy Type of Casing cifications ❑ Public Other ❑ Delta Depth of Grout Seal Type of ❑ Irrigation _!Approx. Depth ❑ Eastern Surface Seal Installed by Repair one ❑ Type of Pump H.P. State Work Done Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 Y TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other r Number of living units: Number of bedrooms t r Character of sail to a depth of 3 feet- Water table depth , SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal x Distance to nearest: Well Foundation Property Line , 1 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 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. a 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." The applicant must call fore all required inspections. C mplete drawing on reverse side. � µ Sig ix- Title: ^��/[`/w v Date: �T 9~ FQfl DEPART NT USE ONLY Application Accepted by -� Date r rea Pit or Grout Inspection by Date Final Inspection by �' at Additional Comments: w 7/7,1, ❑ Stk 466-6781 If Lodi 369-3621 ❑ Manteca 823-7104 ❑ TraW 835-6385 Applicant-Return all {c pies to: E ironFnental Health P)-mit/ 1 E. a;elton,Ave., P.O, Bo�, Stli., CS9 A�, 520�1{,� F AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT''NO. INFO + EH 13-241REV,1/85] Dk � 5 gU EH 1418 i �I