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41 If APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZE T ON AVE., STOCKTON, CAS. Telephone (2091 466-6781 sr F r....Fnr ' - iY• PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED w (Complete in Triplicate) s Wr•1 :._. r 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. f . Job Address �" /�/ City -Lot Size PM �/�j f]` L a Y �N�7 AI ,] y Phon f Owner's Name dress Contract Address - - i n No. D //�hane i TYPE OF WELL/ UMP: E NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK_' SEWER LINES r DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE W OTHER WELL t PITS/SUMPS INTENDED USE TYPE OF WELL ' PROBLEM ARE ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mante , Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ cy Type of Casing f Specifications (1 ❑ Public ❑ Other _. Delta Depth.of•Grout Seal Type of Grout �(v, I' I Installed b 4 El Irrigation �.�ppro pth El Eastern Surface Sea y Repair Work Done ❑ Typeuinp. H.P. State Work Dane 4 Well Destruction ❑ ell Diameter Sealing Material )top 501 x r Depth + Filler Material l8elow 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Q.M DESTRUCTIO (No septic system permitted if public sewer is f e available within 200 feet.) �V3 Installation will serve: Residence Commercial— ;Other-. �t * s _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. ElMethod of Disposal Distance to nearest: Well Foundation Property Line v LEACHING LINE ❑ No. & Length of lines f Total length/size FILTER BED F-1 Distance to nearest: Well Foundation Property,Line 3 SEEPAGE PITS ❑ Depth y Size Number SUMPS ❑ -Distance�to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ v 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.folloWingi '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 t ing: "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 s of Calif nia." i Th applic t st call f all in cons. Complete drawing on aerse side. } Signe r Title:-- Date- t, FOR ate:, FOR DEPARTMENT USE ONLY Application Accepted by Date Area Oa Pit or Grout Inspection Date f Final Inspection by Date j 7 �j 4 " Additional Comments: ❑ Stk 466-6781 ' ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 806385 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 4. EH 13-24(REV.I/a 51 - 3 EH 14-26 _ - r rte-.•. ,.,...s..- i