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h APPLICATION FOR PERMIT .y li SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � - N (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. Job Addressy I f i lK111:,V �.0 hY S KI Ll. City Lot Size PM I� Owner's Name t�. r' rvTS'Address » 2Ph Contractor's Name 1J-_/7��//�K dL " rf Liennsse No. .�L/ 7 Phone TYPE OF WELL/PUMP: I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION E1_.PUMPINSTALLATION ❑ SYSTEM REPAIR ❑ �ER ❑DISTANCE TON ST: SEPTIC TANK SEWER LINES DISP FLD. PROP. LINE F IQN AGRICULTURE WELL OTHER WELL PITS/SUMPS I! INTENDED USE TYPE OF WELL OBLEM AREA CO UCTION SPECIFICATIONS ❑ Industrial .�.,._ L7-Open-Bottom+ ....- LI Mante -- -Dia.'Weil Excavation -- - --� %Dia. of Well Casing C1Domestic/Private ElGravel Pack ❑ Tr Type o Specifications ❑ Pubtic `,j, ❑ Other, .i Delta"- Depth of Grou' Seal e of Grout ❑ Irrigation ---Approx. th ❑ Eastern Surface Seal Installed by"' q A ..: Repair Work Dane ' ❑ Type o mp H.P. State Work Done !i Well Destruction ❑ Diameter Sealing Material (top 50'} t� ° !? Depth �M Filler Material {Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residen I! Commercial T Other t Number of living.units: J Num er of bedrooms_ Character of soih'to a depth of 3h feet: Water table depth �_ SEPTIC TANK Type/Mfg f Capacity No. Compartments PKG. TREATMENT`PLT. ❑ Method of Disposal W Distance to nearest: Wel! Foundation Property Line !i I LEACHING LINE ❑ No.'s& Length of lines Total length/size I` FILTER BED ❑ Distance to nearest:`I� ",Well, =Toundationx P ` Property Line� k- �` SEEPAGE PITS ❑ Depth j Size Number II SUMPS ❑ Distance to nearest:1. Well- Foundation Property Line DISPOSAL PONDS E111. Ij �a ! 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 bistri0t.� # 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 mannereas to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature edifies 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- !i- tion laws of California: The applicant st c I for all required ins ctions C plate drawing on reverse side. f I ' Signed 771! Title: Date: Py„{, FOR DEPARTMENT USE ONLY p Application Accepted by Date w” Area Pit or Grout Inspection by Date Final Inspection by Date . 9i� - Additional Comments: - - !4° ❑ Stk 466-67$10'Lodi—369-3621""' -p Manteca 823-7104 ❑ Tracy 835-6385 11 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE ll INFO AMOUNT DUE AM UNT REMITTED CASH RECEIVED BY DATE PERMITNO. a: + 1324(REV.101831 EH;14-20 EH