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.�� APPLICATION 1=0R PERMIT -:✓" SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—PON AVE:; STOCKTON, CA Telephone (209) 466-6781D � PERMIT EXPIRES 'I YEAR FROM DATE ISSUED I (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. 1$62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 0,16 0 . Job Address f City " Lot Size PM Owner's Name I'd!P �qD RPh?cL ddress S d�P,% 112— Ph .� one Contractor ,_! Address License No. Phone 1 TYPE OF WELL/PUMP: i NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTA NEAREST: SEPTIC TANK SEWER LINES s DISPOSAL FLD. LINE UNDATION AGRICULTURE WELL d OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF W PROBLEM AREA CONSTRUCTION SPECIFI NS E ❑ Industrial ❑ Open Bottom ❑ Man Dia. of Well E ion Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy sing Specifications ❑ Public 0 Other ❑ D Depth of Grout Type of Grout ` ❑ Irrigation I.Appro ❑ Eastern Surface Seal Installed by Repair Work Dane elo# Pump ,, H.P. State Work Done esiruction ❑ Well Diameter Sealing Material (top 50') s Depth Filler Material (Below 501) r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is I'� f available within 200 feet.) Installation will serve: Residence_k� Commercial— Other µ Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK )<Type/Mfg *J 'Capacity No. Compartments PKG. TREATMENT PLT. ❑ 11, ; Method of Disposal Ditance to nearest: Well Foundation Property Line f f I LEACHING LINE ❑ No. & Length of lines ^=� Tota( length/size FILTER BED ❑ Distance to nearest: Welt Foundation Property Line I� SEEPAGE PITS ❑ Depth Size , Number SUMPS ❑ Distance to nearest: Well Foundation Pro pert)Line DISPOSAL PONDS ❑ .II + 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 Sanl�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." I� The applicant must call for all require i pections. C mplete drawing on reverse side. Signed Q - Title: Date: 3 ` FOR DEPARTMENT USE ONLY Application Accepted by Date �� rea Pit or Grout Inspeetio Date Final Inspection by Date» r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 1369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354KM Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r � FEE INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. r+i 1gEV 1s-24 .,,es, EH 14-28 "' D II