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APPLICATION FOR PERMIT .. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA �c Telephone {209} 466.6781 L� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r`o � X� ] 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. 1562 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 1 Job Address �� f0 nt C.i L City Lot Size x 7 . PM Owner's Name :TeN( IC'A �'CAvnlb Address Vk Phone 9 .4 �i Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �- PUMP INSTALLATION ❑ SYSTEM REPAIR Llf OTHER ❑ � 1. DISTANCE TO NEAREST: SEPTIC TANK SEWERf LINES DISPOSAL FLD. PRO ""-FOUNDATION AGRICULTURE WELL OTHE PITS/SUMPS INTENDED USE _TYPE OF WELL PROBLEM AREA CO ON SPECIFICATIONS � ❑ Industrial—,_ ❑ Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Cl Gravel Pack racy Type of Casing 4 Specifications { ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i ❑ Irrigation `' pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Don Type of Pump H.P. State Work Done Well Des ion ❑ Well Diameter Sealing Material atop 501. t Depth Filler Material (Below-501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (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 Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well-'-- Founeation z,- � ' 'Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation `� "� Property Line SEEPAGE PITS ❑ Depth Size j :Number SUMPS ❑ Distance to nearest: Well Foundation '"^-" Property Line DISPOSAL PONDS ❑ } 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 persons subject to workman's compensa- tion laws of California." The lica ust call for II requirfd inspections. Complete drawing on reverse side. ( 15-11 � Signed r Title: `c 'L` - t-,c�-"ter' Date: v U� 4 FOR DEPARTMENT USE ONLY �t`l14by D�.. Application Accepted by � DArea o� Pit or Grout fnspectio Date Final InspectionDat. I Additional Comments: � ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ MaNt6 823-7104 ❑ Tracy 85 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,CA 95201 FEE INFO MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE .7/e51 �� •vim ' 3spo Vit CPERMIT''N0. + EH 3-24(RSV 29EH1JOS e 1-1343