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APPLICATION FOR PERMIT 41P SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781_ ., PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a ' - (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. Job Address Lot Size l osle PM Owner's Name �L?'/ rf Phone Contractor ssf ense No/ ' Phone 7 TYPE OF WELL/PUMP: NEW WELL ❑ WALL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ R ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SAL FLD.1�_ PROP:LINE; FOUNDATION AGRICULTURE WE OTHER WELL v PITS/SUMPS` INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS MI ► "'j' 't '° ''' ❑ Industrial ❑ Open Bottom nteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pa ❑ Tracy Type of Casing':" Specifications � ❑ Public ❑ r ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by s i Repair Work e ❑ Type of Pump f H,p ^i State Work Done Well D ruction ❑ Well Diameter Sealing Material (top 501 Depth'" ' " =*'illw_ r'Ma'erial (Below TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION V DESTRUCTION ❑ (No septic system permittedrif public sewer,is t available within 200 feet.) y"V Installation will serve: Res ecce_ Commercial - Other T- pp��CC,, Number of livingunits: Number of be0fooms w ? f � I I Character of soil to a depth of,3 feet- _' ".t V1/atert lble'depth SEPTIC TANK ❑ „Type/Mfg ' Capacity No. Compartments` 4 PKG. TREATMENT PLT. O ` I Method of Dispo DsalS5istance to nearest: Well _ Foundation + ' Property Line 4-41 LEACHING LINE ❑ No. & Length of lines Total length/size i�P- g FILTER BED ❑ Distance to nearest: Well Foundation t Property Line wtic 01 " SEEPAGE PITS DF pth Size Number a SUMPS ❑ Distance to nearest: Well 60 Foundation Property Line 2�r .�. a. DISPOSAL PONDS ❑ -••-•- •--•----�--- -•� --4-�... _ � � I hereby certify that I have prepared this application and that the work will be done in accordance with.San Joaquin county ordinance's, state laws, and rules and regulations of the San Joaquin Local Health District. , ?* , +1. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which Hythis7permtt is issued, I shall not I 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 iemploy persons subject to workman's compensa- tion laws of California." The applicant r all required in c ns. Complete wing on rev rseside. �+ Signed t Title: #_ 4 + 7� ,e .t, � �� Date: ay FOR DEPARTMENT USE ONLY J Application Accepted b Date f 2-_ .-0 _.Area Pit or Grout Ins ecti 12..•�fi ;; ` 1^ P Y Date Final Inspection by Date tL Additional Comments: t J� I. 1;4_ I ❑ Stk 466-6781 , ❑ Lodi 369-3621 ❑'Manteca-823-11-04 OlfrTcy 835-6385 OIL Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK t RECEIVED BY DATE PERMIT`N0. INFO CASH + EH1324(REV.t/95) ��,®� t ��/1 /Da 1p- )! EH 14-26 J Wi �3 W !fB