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"�- .. — APPLICATION FOR PERMIT y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E._ HAZEL T ON AVE., .STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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 Address 1,577Sl ,6,1 "V_, City Lot Size PM Owner's Name Alen r Address' ` ' Phone Vf- Contractor Address] !,.- .� "•( 1iC'l V� / License No. Phone F 71 TYPE OF WELL/PUMP: NEW WELL ❑ WELL'REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES AL FLD. ��2 PROP. LINE "'Y FOUNDATION AGRICULTURE WELL OT1 ER WELL PITS/SUMPS INTENDED USE;---Approx ELL PROBLEM AREA STRUCTION SPECIFICATIONS ❑ Industrial Elttom antec Dia. of Well Excavation Dia. of -Well Casing ❑ Domestic/ Privateack ❑ y Type of Casing Specifications ❑ Public Delta Dept out Seal Type of Grout ❑Irrigation x pth ❑Eastern Surface Seal Ins by ..��-..Repair Work Done# ❑p ^ H.P. �ork Done Well Destruction ❑er Sealing Material (top 50') Filler Material (Below 50'1 TYPE OF SEPTIC WORK: ,NEW INSTALLATION ❑ REPAIR/ADDITION 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___.__; i Character of soil to a depth of 31eet`.� y Wa er able dePssk 1''k. SEPTIC TANK ElTypelMfg A, Capacit No -ompartme l PKG. TREATMENT PLT. ❑y ti , a Ci eth of Disposal Ir ' i - Distance to nearest: Well Foundation Property Line �_ LEACHING LINE �1 No. &Length of lines "'~ � _ Total length/size FILTER BED ❑ Distance to nearest:" Well Foundati� S Property Line . SEEPAGE PITS ❑ Depth s --Size rj Iti - '- Number a. SUMPS Distance to nearest: Well' / Foundation •� � Property Line ii DISPOSAL PONDS *+ f I hereby certify that I have prepared this application and that the work will be`donne irk accordance with San Joaquin county ordinances, state laws, and f rules and regulations of the San Joaquin Local Health District. ' % r Home owner or licensed agent's signature certifies the following* "I certify that in the performance of the work for which this permit is rued, I shall not I employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring-or_sub-�ontr1acting signature F 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 Califorriia." +?_ • J }{ The applicant must'call for all requirepectior.. Complete drawing on reverse sicl f �! Signed X r. , ! Title:3 (/, i�-t J Date: FOR EPA FITMENT USE ONLY Application Accepted by 1 f Date Area "` Pit, or Grout` Inspection by r 1 Da Finahlnspection by Dat A AdditionahComrXentss- idti tk-'466-678"1 —D -Lodi -369-3621 &. ❑ Manteca 823-7104 ❑ T Applicant "Return all copies to: Enviro,hmehtal Health Permit/Services 1601 E. Ha 835-6385] Ave., P.O.. Box 2009, Stk., CA 95201 .t i INFO AMOUNT DUE T AMQUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. ' -+' EH 13-24(REV: 1iH57 - EH 14-26 - F•}+ ]�1 „i41„i a '" �� ,R/} C"�.e,� Zy�� - 2