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kiw 3 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT s 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781r< , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �'�'' r :=x; (Complete in Triplicate) D L —Z 33� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work i ri-wrtbsd.This appfieatfoar In made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rube and gowwiom of th San Jogttirt r Local Health District. — H ? Job Address " '�1 Lot Sire 2 pct Owner's Name - b .(�C1�f/1��' Address phone ^� OF Ai Contractor's NarneAL, t ^p_ License No. t TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ L PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDAT!ON AGRICULTURE WELL OTHER WELL PRS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑Open Bottom ❑ Manteca Dia.of W1:11 Excavation Dia.of Well Casing ❑ Domestic/Private ❑Gravel Pack ❑Tracy Type of Casing Specifications -. `O ❑ Public G Other ❑ Delta Depth of Grout Seal Type of Grout j ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done � Well Destruction ❑ Well Diameter Sealing Material(top 501 0 l Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION RE PAIR/ADDITIONX DESTRUCTION IkINo septic system permitted if public sewer Is available within 200 feet.) + Installation will serve: Residence— Commercial_ Other Number of living units: _3_ Number of bedrooms - Characte•of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity_ No. Compartments _ Q PKG. TREATMENT PLT.❑ Method of D' .} Distance to nearest: Well•CQ It/Foundat!on _?0& Property Line LEACHING LINE LI—No. & Length of lines ��,�,,To��fength/size FILTER BED C1 Distance to nearest: Well /0 Foundation . 1 Property Line SEEPAGE PITS a7 Depth Size XNber SUMPS ❑ Distance to nearest: Well FoundationaProperty LineDISPOSAL 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. F 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 shah not w 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 folkrwing:"I certify that in the performance of the work for which this permit Is issued,I shall employ persons subject to workman's compense- > tion laws of Cal fofnia." ?F- The applicant urt call for all required in ions. Complete drawing on reverse side. +i Signed '1"�• ��'3— Title: /��'�YI Date: i X FOR DEP FITMENT USE ONLY Application Accepted by Date Area �PJt or Grout Inspection by r z ate x �' Final Inspection by / -P��' // ri ='z JData �i�2 A 'Tonal Comments: $tk 4ffii-Ml C3 Lodi 389.3621 ❑ Manteca 823-7104 ❑Tracy 8355385 f cant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE AMOUNT DUE AMOUNT REMITTED CK s RECEIVED BY OATS PERMIT*NO. INFO CASH i EH i �� Cl3/fro $b-li 7 . 13-24 REV 10/®1 Lt EH 14-26 1