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APPLICATION FOR PERMIT S SAN JOAQUIN LOCAL HEALTH DISTRICT ._1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 1_ PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) .Application is heieby 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. ( C Job Address J I�- $[il7.Q--a City J Lot Size PM Owner's Name � =MCAs n Address LP—2- �S t� LTl b� Phone Contractor L !' Address License No. Phone 'TYPE OF WELL/PUMP:- NEW WELL ❑ WELL REPLACEMENT.[] DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK . SEWER LINES DISPOSAL FLD. . LINE FOUNDATION AGRICULTURE-WELL,- OTHER WE PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIO IFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Di ell Excavation Dia. of Well Casing D Domestic/Private D Gravel Pack « ❑ Trac Type of Casing Specifications F] Public Cl Other eita Depth of Grout Seal Type of Grout I I Irrigation Depth E I Eastern Surface Seal Installed by _ Repair Work Done ype of Pump H.P. State Work Done _ Well Dest on D Well Diameter Sealing Material {top 50') Depth Filler Material IBelovv501 -TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) ` 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 I SEPTIC TANK ❑ Type/Mfg ,Capacity " � '.. No. Compartments F PKG. TREATMENT PLT. ❑ Method of Disposal r Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines Total length/size FILTER BED D Distance to r earest: Well Foundation - Property Line SEEPAGE PITS I ] Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ " I hereby certify that I have prepared this applica_tion.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." c ust call for�regwu'ir inspections. Complete drawing on reverse side. Signed �L.9-.vt.F� Title: � Date: DEPAgTMENT USE ONLY Application Accepted by V �1�/" l�l�l Date Area Pit or Grout Inspection by Date Final Inspection by 1 4 Date 7 Additional Comments: U r f7 0r- ! la Stk 466-6781 Lodi 69-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ,Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED % RECEIVED BY DATE PERMIT'NO. INFO (y , + EH 13-241REV.riMsl ��-�(.l ^, t � 3 f � 3-mo - -EH 14-26 _ a t,�I \'U11{��U L L