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►mow kk �' � � .. T I APPLICATION FOR PERMIT ill SAN JOAQUlN LOCAL HEALTH DISTRICT 1601 E. HAZE."i ON AVE., STOCKTON, CA Telephone (209) 466-6781;, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' `►vc .: i (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. t r c Job Address _ 1 fJj�i1 City 577f& ,e Lot Size 76 fawl PM Owner's Name 4.0 oil w.r+It�1�it/ Address ,j S a £�f t`/�icL lrr�i Phone Contractor L�s�.4�../� Address License No..TdBLJ Z- Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ k DISTANCE TO NEAREST: SEPTIC TANKS S ER LINES '`DISPOSA FLD. PROP LINE FOUNDATION N AGRIC TORE WELL OTHER WELL PITS/SUMPS r �{ INTENDED USE TYPE OF WELL PROBLEM AREA IkSTRUCTION SPECIFICATIONS ' ❑ Industrial ( ❑ Open Bottom © Mant Dia. oll'Well Ezca"vation_. Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Ca ' g - Specifications { ❑ Public ❑ Other 's ❑ Delta Depth of Grout eal Type of Grout ❑ Irrigation _.,..-_Appr epth ❑ Eastern SurFach Seai If d by t Repair Work Done ❑ Type ump H. a ° . tate Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 n Depth Filler Material (Below 501 + TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑.,-DESTRUCTION 11.F-(No septic system permitted if public sewer is I� available-within 200 feet.) Installation will serve: Residence_ ;!Commercial_ Other�� .'t O Number of living units: - Number iof bedrooms .<: r: .. e Character of soil to a depth of 3 feet: ¢" Water table depth' SEPTIC TANK D Type/Mfg �� fE' Capacity_ _ No. Compartments , PKG. TREATMENT PLT:C7 _y. '. Method of Disposal k Distance to nearest: Well ..� Foundation Property Line T LEACHING LINE ❑ No. 6 Length of lines Total length/size r h FILTER BED ❑ Distance to nearest: Well undati Property Line + � I@ SEEPAGE PITS ❑ Depth Size Nu bar SUMPS ❑ Distance to nearest: Well Foundation Property Line ` DISPOSAL PONDS ❑ 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 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." Th ant must call for all required inspections. Complete drawing on reverse side. f Si ned Title: - —Date: r OR DEPARTMENT USE ONLY ` Application Accepts y s Date Area ' Pit or Grout Inspection by Date Final Inspection by Date r ..,...._._ Additional Comments: it ❑ Stk 466-6781 ❑ Lodi 369-3621 If ❑ Manteca 823.7104 ❑ Tracy 8354M 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 II, FEE INFO AMOUNT DUE .1I` AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + Eli 13-24(REV,i i R sY 35'Zrx EH 1426 CV/