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t3. 4 k� APPLICATION FOR PERMIT ` �IA SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES t YEAR FROM DATE ISSUED IComplete 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 City S-4MA Lot Size PM I{{{� Owner's Name - ddress--. 7%1 3tJ /j.O`t flY[_ Phone/ / i Contractor ddress Q a:�A� C_. ense NoI U17< a Phon�! u TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 171 OTHER ❑ DISTANCE TO NEAREST: NK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION CULTURE WELL_ OTHER-WELL. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARE tL111-11 CATIONS— ❑ Industrial ❑ Open Bottom ----E5- anteca Dia. of Well Excavation Dia. of Well Casing n- Domestic!PrivatePack ❑ Tracy Type of Casing ications F PublicOther ❑ Delta Depth of Grout Seal Typo of Grout I I Irrigation _-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, .. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material {top 501 -- Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION la REPAIJADPITION I 1 WTRU ION (No septic system permitted if public sewer is 7 available with 00 feet.)_._ Instaflation will serve: Residence Commercial--- Other-.�Number,of living units: Number of bedrooms r Character of soil to a depth of 3 feet: +- ' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity ' No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundationt Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size t FILTER BED ❑ Distance m nearest: Well Foundation Property Line i SEEPAGE PITS 11 Depth Size Number 1 SUMPS r Cl 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." The applicant usI call for II require inspections, Complete drawing on reverse side. lk Signed X f Title: I \ L2-, e-)XI Rate• FOR DEPARTMENT USE ONLY Application Accepted by h Date Pit or Grout Inspecti Date Final Inspection by Date V'd' ' L t� Additional Comments: ��-'Cr. rT' - i L- U ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 8.23-7104 ❑ Tracy 835-6385 4 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 RECEIVED BY DATE PERMIT NO. INFO CASH ` + EH 13.241HEV.1/n sl , (� 1 EH 14-26 'tet/:e �-:� 4 �n