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APPLICATION FOR PERMIT a I ,J��L' SAN JOAQUIN LOCAL- HEALTH DISTRICT 1 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone'(209)'466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l Complete in Triplicate] Tt 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. W" Job Address J I �R �i ll]a City Lot Size �a PM Owner's Name - Address -_ / Y r Phone Contractor()`-0L fl Address License No. 9C V Phoneg TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t DISTANCE TO NEAREST: SEPTIC ANK SEWER LINES DISPOSAL FLD. PROP. LINE FOU ATION AGRICULTURE WELL OT R WELL — PITS/ MPS f INTEND/e171 PE OF WEL PROBLEM AREA CONSTRUCT NSP IFICATIONS ❑ Industriapen Botto 71 Manteca Dia. of W Exca tion Di of We asing r ❑ Domestiavel P k ❑ Tracy Type of/Gr pacific ions ❑'Publicher t ❑ Delta Det oSeal T t pye f Grout❑ IrrigatioA prox. Depth ❑ Eastern S acestalled by Repair Worf Pump W.P. State Work D rteWeil DestrDiameter Sealing aterial (top 50'1h Filler Material {Below 50') J TYPE OF SEPTIC WORK: NEW INSTALLATION REPA.IR/ADDITIONR DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: L— Number of bedroo s Character of soil to a depth of 3 feet: Water table depth ` SEPTIC TANK ❑ Type/Mfg Capacity Z No. Compartments } PKG. TREATMENT PLT" ❑ Method of isposal Distance to nearest: Well FoundationA Property Line o6 12 ot LEACHING LINE No. & Length of lines ti VP V Total length/si e. r , FILTER BED ❑ Distance to nearest: * Well�C! FoundationProperty Line +1[ ' SEEPAGEE'PITS� �`"""'"C11Oepth4t Size � ~ !Number + ' SUMPS _ . .Distance to-earest:: Well ^a< Faondation `Property Line DISPOSAL PONDS " ❑l 6, x 'rr � I hereby certify het`l have prepared this application and that iiie-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 o�iicen'sed'.agent's signature certifies the follo+tiing: "/'certify that 6 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." r r ^ { T - " The applicant must call for all required inspections. Complete drawing on reverse side. Signed X d,-1 t Z"i r i i tTitle: t(�n` —�!'Cd C.,i C�r = Date: `— OR'UE TMENT-USE ONLY f�,E " IF Application Ac ep d by Datey Area f A •� S a4-- - .s�: !^'.r.+,�n^^rww..rs--.n.0 :� _ '"d. `i'S•`--.--�-1 - - Por G ....'..�... - i rout Ins Vr/ tInspection by '� � Date ` Final Inspection by -� ,�$te ' " Additional Comments`'' , ❑,Stk,,.466-6781,..—❑-Lodi -369-9621 - - 3-Manteca--'823-7104.. H-Tracy'"835-6385"""" '"'"" . - -''Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,.Stk., CA 95201 FEE INFO AMOUNT DUE, AMOUNT REMITTED CASCK H RECEIVED BY DATE PERMI7 NO. + EEH H 14-24IREV-i/H sl O " .y.-_ ,1 r3q