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OF �. '7APPLICATION-FOR.. PERMIT SAN JOAQU N LOCAL HEALTH DISTRICT 1w;1 � } 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 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.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. e6 � f Job Address !- City Lot Size. PM I Owner's Name l �bL'Y, � Hdress Phone r Contractor Address__C=NC%Z> V .�.lm u2fr " License No. Phone -� TYPE OF WELL/PU ! " NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION CI PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ " DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE (� FOUNDATION AGRICULTURE WELL OTHER PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONS SPECIFICATIONS_ ., ` 1 - 1 5 t ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack cy Type of Casing F'"' Specifications' ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation prox. Depth ❑ Eastern Surface Seal•lnstalled by or ` I Repair Work Done Type of Pump H.P. y State Work Done Well Destr ' n ❑ WeIL�`Diameter Sealing"Material (top 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ "REPAIR/ADDITION-❑--DESTRUCTION �-INoseptic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms f Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ' Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ` 4' s Distance to nearest: Well Foundation Property Line� LEACHING LINE ❑ No. & Length of lines Total length/size s FILTER BED ^"' r ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS r Deptfi rte- Size Number SUMPS = ❑ Distance to nearest:'`+w Well Foundation Property Line DISPOSAL PONDS i Cl I hereby certify"'that I have prepared"this application and that the work will,be done in accordance with San Joaquin county ordinances, slate 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.perf6rmance 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 certi -that in the" rforrnance of the work for which this i ". , fy' pe permit is issued;I shall employ persons subject to workman's compensa- tion laws of California." The a piicant m must II for all required inspections. Complete drawing on r ' rse side. 5i ned Title: A T - g �� 1J �_ Date: FOR DEPARTMENT USE ONLY V V� �y Application Accepted by Date Area Pit or Grout Inspection b Date Final Inspection by G Date ` Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621` ❑ Manteca 823-7104 Tracy 835-Em c� �s Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE t INFO rAMOUNT DUE AMOUNT REMITTED rA$R RECEIVED BY DATE PERMIT"NO." + EH 13-24(REV.1/a 5} �" - Ek 14-29 F`n L• 4�D