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f 1. aP APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 21' �► 1"1 Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. LJ�bAddress 100 d �1 t i(31 _ City Lot Size PM er's Name l]-15 �� J Address 1 a Phontractor �]P� T_ _Address PAU License No. . Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIO ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE-" FOUNDATION AGRICULTUR ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE AR CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Monte Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack: ❑ T cy Type of Casing '' Specifications' [7 Public F-} Other Delta Depth of Grout Seal Type of Grout I I Irrigation .-Approx. Depth ( Eastern urface Seal Installed by Repair Work Done ❑ Type of Pump, H.P. State Work Done Well Destruction ❑ Well Diameter i Sealing Materi I it, 501 i V Depth Filler Material 1Below,50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION {.l DESTRUCTIO Wo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms ' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK' 1-1 Ty 1 No. Compartments V . -, PKG, TREATMENT PLT. EJ I � a ty .,Method of Disposal �r Dis once[o neast: WeII Foun ation Property Line Dormi may ha11t, RXCIICQ Wit�ou�t LEACHING UNE ❑ No. & epgth o Total length/size �1 tYw Liqui iv tt FILTER BEd ❑ Dista c o nearest. V11e n Property Line �. SEEPAGE PITS i I Depth Size, Number I SUMPS Ll 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 must call for all required inspections. Complete drawing on reverse side. yy Signed X Title: .CAA]h Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area /nj :Pit or Grout Inspec o y Date F anal Inspection by Additional Comments: V 1 u's a rM k S 4L�_13: 4-19113 4 ❑ Stk 466-6781 11 Lodi 369-3621 C3 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies ty,fnvironmental Health Permi /Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 V(1/ r-e v -6t ruYh FEE AMOUNT DUE AMOUNT REMITTEDC K H RECEIVED By DATE PERMIT'NO. INFO ' a EH 13-24(REV, /H sY �S__IJ� �S •0 0 EH 14-26 111 F, r