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APPLICATION. FOR PERMIT x SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA * � Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (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. .S Job Address _IL7 , �{(f 1-S � City t, Lot Size -47-Ce.C2 iG5 PM Owner's NameI��C1 j [J�P Address 3_ 3 Al e)(, K_&� Phone 1-1 i l E tG Contractor 1 ,V Address�l;r�.r�� 'T > _ 2 /1 License No 15?-3g3hone - �7 TYPE OF WELL/PUMP; IqEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR LJ OTHER 13 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .� DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE,VIIELL OTHER WELL PITS/SUMPS�. t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ;r j ❑ Industrial Open Bottom ❑ K6nte6a Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Grave! Pack L3Tacy Type of Casing �G'� Specifications 1 'k Type Public f] Other C] Delt'aJ' Depth of Grout Seal Type f Groutl'Fel-st e-11 I F ' � . r -installedbv 1 1_Irrigation Approx. Depth I Eastern S , e Repair Work Done ❑ Type of Pump H.P. State Work Done l r r — 1Nell Destruction ❑ Well Diameter Seating Material (top 501 t, Depth -- -- Filler Material (Below 501 k� f TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 'REPAIR)ADDITION I I DESTRUCTION I 1 lNo septic system permitted if public sewer is r r available within.200•feet.)„_„ rInstallation will serve: Residence_ Commerciaf_ Other E Number of living units: Number of bedrooms• h s i Character of soil to a depth of 3 feet: .y • ` ' p '~. '�' Water table depth SEPTIC TANK ❑ Type/Mfg I r fR Capacity No. Compartments ? PKG. TREATMENT PLT. ❑ T ;� {� - Method of Disposal Distance to nearest: Well. ' "Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines h Total length/size FILTER BED ❑ Distance to nearest: Well t Foundation Property Line SEEPAGE PITS i I Depth Size 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 Disstrict. r Home owner or licensed agent's signature certifies the following,"I certifythat 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." 4 The applicant must call for all rec;pireo inspections. Complete drawing on reverse side. Signed X a Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date ! Area Pit orro t inspection brr Date 1?� Final Inspection b�. Q Date r t Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -823-7104' ❑Teacy 835-6385 —Applicant--Return-all"copies-to:'Environmentat-Haatth-Permh/l ierviees-1601`'E:`Hazelton Ave.,^P.-O`Box 2009,-Stk:, CA 95201 —FEE r INFO AMOUNT DUE' AMOUNT REMITTED CASH RECEIVED 6Y DATE PERMET'NO. +-EH 13-24(REV.i R5) p 212 26 EH 14- ✓ r !� -07�