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APPLICATION FOR PERMIT CD ., SAN JOAQUIN LOCAL HEALTH DISTFI# 1601 E. HAZELTON AVE., STOCKTOlil D# 49 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DAT (Complete in Triplicate) In'u y 1 c�pry INV## b / Application is hereby made to the San Joaquin Local Health District for a permit to construct and II made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the u es Local Health District. d Job Address _ 47City Size 3 (, PM l �( c Owner's Name Address -{bo C4 Phone " r+J t. Contractor � ddress - r License No� �J t+ Phone��51_ 94 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ V PUMP INSTALLATION ❑ - SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWERNES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICU URE. LL OTHER WELL PITS/SUMPS _ `rr INTENDED USE TYPE OF WELL PROBLEM AR 0 STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom :�IDelt anteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications ` 1'1 Public ❑ Other -Depth of Grout Seal Type of GroutI i Irrigation _Approx. Depth Ia ern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P State Work Done_ 44 Well Destruction ❑ Well Diameter Seal g Material (top 50') N Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION FlREPAIR/ADDITION ( I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial t i Number of living units: Number of bedrooms i. Character of soil to a depth of 3 feet: Water table depth V" SEPTIC TANK ❑ Type/Mfg 0 Capacity—L2—L) No. Compartments PKG. TREATMENT PLT. ❑ / Method o Dispo a Distance to nearest: Well Foundation /d Property Line LEACHING LINE ❑ No. & Length of lines r+ yti A T al length/size 4 FILTER BED ❑ Distance to nearest: Well �/�6dundation Zf7 Property line SEEPAGE PITS I I Depth Size ber Uli /Of_ w SUMPS ❑ Distance to ne rest: Well Foundation Property Line DISPOSAL PONDS ❑ 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,I shall employ persons subject to workman's compensa- tion laws of California " The applicant must fo�all requi spections omplete drawing on reverse side. Iff Signed X + Title: U,LA/1'1.-H z Date: ( — / r OR DEPARTMENT USE ONLY Application Accepted by Date Area y ` Pit or Grout Inspection by Date Final Inspection by I�i� Date !7_'14Y ' / v Additional Comments: /a 47S u.'N L'i't 17Af� ajt E) Stk 466-6761 ❑ Lodi 369- 1 ❑ Manteca 623-7104 ❑ Tracy 635- 5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 w. � I INFO AMOUNT DUE AMOUNT REMITTED CASHy/I REC�EIV�ED/BY (/ D7ATE/r PERMIT2N)O. ♦ EH 124 IREV.1/N5/ ! 670 F • rl EH 142E