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F 4 APPLICATION FOR PERMITIn 1 � �--nw�R SAN JOAQUfN LOCAL' HEALTH DISTRICT No Nli 1601 E. HAZEL T ON AVE., STOCKTON, CA i' Telephone (209) 466-6781 -4 f. t i- I PERMIT EXPIRES i YEAR 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, Th{s 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, _ C Job Address S�T. City SUC 4-ot Size PM Owner's Name P ; , .0 e cle HiQ Address Z 5 d Iv° 37 Phone 9 Gd Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIO"N ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL UMPS INTENDED USE TYPE OF WELL PROBLEM AREA. _CONST.RUCTI (CATIONS ❑ Industrial C] Open Bottom ❑ Manteca . o Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Type of Casing Specifications ` { ❑ Public ❑ Other ' ❑ Delta Depth of Grout Seal Type of Grout 1 ❑ Irrigation 4 pprox. Depth ❑ Eastern Surface Seal Installed.by Repair Work Do T s�..r...`_` p 1 Type of Pump H.P. State Work.:Done_ Weil D ction ❑ i, Well Diameter Sealing Material (top 50'I f f� Depth. Filler Material (Below 501 TYPE OF SEPTIC WORK: .NEW INSTALLATION ❑- REPAIR/ADDITION'❑"'DESTRUCTION iNo septic system permitted if public sewer is a available within 200 feet.) Installation will serve: Residence_ Commercial_ Other" Number of living units: I Number of bedrooms ' Character of soil to a depth of 3 feet: { Water table depth SEPTIC TANK j❑ , Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT!❑ " Method of Disposal i Distance to nearest: Well I FoundationProperty Line ' LEACHING LINE ❑ No. & Length of lines Total length/size Y FILTER BED ❑ :Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ ! Depth Size Number kr SUMPS ❑ t..Distance to nearest: Well . -Foundation Property Line DISPOSAL PONDS ❑ 1 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 Califor .The am all for"all'requit-m in--ctions:Complete drawing on rever�srye side: ^�3 igned X '`Title: - - 0 At Al ['r✓ Date: — `` v FOR DEP RTMENT USE•ONLY '4 Application Acce ted b PP p. Y - ZLr Date �� Area Pit or Grout Inspection by ----- --- Date— — Final-Impigction"tiyc '-` - Date 13 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 - ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE F INFO AMOUNT DUE AMOUNT REMITTED CASH CK-11 RECEIVED BY DATE PERMI7'N0. a EH 13-24{REV.I 57 �& EH 74-ZB i