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f , APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED IComplete 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 �� + A��2 �d� City SII Lot Size b5 ✓lil1 f PM Owner's Name 4Aw-56,.ff Address 5... Iat/�9�/Yt'.e _49,6-1C Phone Contractor Q t?.G Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DIST SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FO N AGRICULTURE WELL OTHER WELL /SUMPS INTENDED USETYPE OF WELL LEM AREA CONSTRUCTIONS IONS t ❑ Industrial ❑ Open Bottom ❑ Mantec a Excavation Dia. of Well Casing q ❑ Domestic/Private ❑ Gravel Pack f Casing Specifications v`1 M Public Cl Other C1 Delta Depth of Gr eal Type of Grout I I Irrigation - Approx. Depth I 1 Eastern Surface Seal Installs _ f Repair Work Done Type of Pump H,P. State Work bone_ Well Destructi ❑ Well Diameter Sealing Material Ito, 50'I Depth! i -Filler Material(Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION l I DESTRUCTION (No septic system permitted if public sewer is Iav ailable within 200 feet.) r Installation will serve: Residence_ Commercial— Other Number of living units: p Number of bedrooms t Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg ' Capacity No. Compartments PKG. TREATMENT PLT. ❑ I r f, ° Method of Disposal Distance to nearest: Well Foundation Property Line '"�" �"' LEACHING LINE ❑ No. & Length of lines Total length/size a t � FILTER BED ❑ Distance to nearest: Well Foundation Property Line '•°�-..+ SEEPAGE PITS 11 Depth Size Number SUMPS ❑ Distance to nearest:'^-^"Well^- -—Foundation Property Line DISPOSAL PONDS ❑ 4 r 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 call for al uired inspections. Complete drawing on reverse side. Signed XTitle: Date: FOR (DEPARTMENT USE ONLY Application Accepted by Date ZArea t I y Pit or Grout Inspecti y —-_ Date Final Inspection by Date 0 k Additional Comments: f r ❑ Stk 466-6781 ❑ Lodi 369 ❑ Manteca 823-7104 ❑ Tracy 835-6385 R Applicant- Return all copies to: Environmental Health Permit/Services 1601 It.-Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO r�{� +.EHt3-21 1flEV,t i k 5r E. Qt3 O y�✓d ��s EH 14-28 11 -i