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,r APPLICATION FOR PERMIT � y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 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. o f Job Address (� Ud C" City 16)1 Lot Size !" PM _._ u Owner's Name / -AAddress /� [sem ?rLie6 Phone "Contract 0!1 fU�,4«` !I _Address License No. Phone TYPE OF WELL/PUMP: al. NEW WELL ❑. WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ � 'OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSALS,FLD. PROP. LINE FOUNDATION. AGRICULTURE WELL OTHER WEL PS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIO CATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ell Excavation Dia. of Well Casing ❑ Domestic/Private 0:Gravel Pack ❑ Trac —Type of Casing Specifications ` i'1 Public Cl Other - Delta Depth of Grout Seal Type of Grout--- I I I ] Irrigation -A Depth I ! Eastern Surface Saul Installed by Repair Work Done ype of Pump H.P. _ State Work Done Well Destru ❑ Well Diameter Sealing Material (top 50')a Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIRIADDITION l I DESTRUCTION INo septic system permitted if public sewer is , /t available within 200 feet.I �/ 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 r.. SEPTIC TANK ❑ a Type/Mfg Capacity No. Compartments PKG.-TREATMENT PLT. ❑ u Method of Disposal Distance to nearest: Well Foundation Property Line f LEACHING LINE ❑ No- & Length of lines Total length/size FILTER BED ❑4 Distance to nearest: Well Foundation Property Line 4 SEEPAGE PITS I I s. Depth Size Number SUMPS L)i` 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,1 shall employ persons subject to workman's compensa- tion laws of California." 11 The a licant must Il t all required inspections. Complete drawing on reverse side. -f Il Title: �/'� Date: a � I Signed X I� FOR DEPARTMENT USE ONLYIll, I 7 n Application Accepted by I' � '` Date y "'��4 r Area Pit or Grout Inspection by Date Final Inspection by ICUL `-' - Date -act Additional Comments:`r t' ��E7— ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 423-7,UK ❑ Tracy 835-6385 Applicant - Return all copies Environmental Health Permit/ ices.1601 E. Hazelton Ave., P.O. Box 2005, Stk., CA 95201 ` . C-1— k4 Zs, U"" actk1 �- FEE INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT N0. t r CASH ♦ EH 13-241REV.1/851 1 ^�� r r,3 ��- ""'� ! �'lr 4/ (^�"' EH 14-28 ;/