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5 APPLICATION FOR PERMIT tc SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 N �..� PERMIT EXPIRES 1'YEAR FROM DATE ISSUED N C"�' 11DI71 (Complete in Triplicate) ^' t d4 8 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 welUpump and the Rules and Regulations of the San Joaquin L al Health District. Job Address `�<S r r q-nZ Y— r ! 1! Q City SID Lot Size PM Owner's !Name S�(ddtSY Address �+ V� Phone Contractor Address License No. Phone TYFSE OF WELL/PUM : NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CON STRUCECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications f7 Public ❑ Other Oita Depth of Grout Seal Type of Grout I I Irrigation _..Appro pth I I Eastern Surface Seal Installed by Repair Work Done ❑ �W.11 Pump H,P. State Work Done_ Well Destruction iameter Sealing Material atop 501 Depth Filler Material (Below 50') T F SEPTIC WORK: NEW INSTALLATION [I RLPAIRIADDITION l I DESTRUCTION f (No septic system permitted if public sewer is 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 3 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 3 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS Ll 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, I shall employ parsons subject to workman's compensa- tion laws of California." The applicant m st call for all required inspe tions. Complete drawing on reverse side. Signed X _ Title: C. Date: FOR DEPARTMENT USE ONLY C Application Accepted by Date S-3, 8 G Area I Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: tl i .� ��b-775 f +SyL-L_e_ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63851 (,� L�_dil C6 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE f� INFO AMOUNT DUE AMOUNT REMITTER CK CASH/ /RECEIVED BY DATE PERMIT-NO. +.EH 13-24{REV.i i sl �S a�� V o _(.h / !f J&6?y EH 14-26 CY'� !I7