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41 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 1 mf<N704 Telephone 12091 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. Job Address ,J->2 j5L4` 17Q4 �d./,1]/?�il�.i�+ _�--I-_—� �� d/ City Lot Size PM Owner's Name Y—��AAeJ7Z Address tPhane 1 Contractor Address &WILicense No. Phon TYPE OF WELL/.PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C7 �.. _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P FOUNDATION AGRICULTURE WELL OTHE PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA---CO NS NwSPEGINGATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack acy Type of Casing Specifications I 7 Public ❑ Other C] Delta Depth of Grout Seal } Type of Grout I Irrigation _;Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work ❑ Type of Pump s H.P. State Work Done estruction ❑ Well "meter Sefaling Materia! (top 50'1 Depth Filler Material(Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION 1.3 REPAIR/ADDITION I ] ._DESTRUCTION fNo septic system permitted if public sewer is t } available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Character of soil to a ep; of 3 feet: r # t Water table depth SEPTIC'TANK Type/Mfg `Capacity No. Compartments f� PKG. TREATMENT PLT. ❑ Method of Disposal � ) P Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property tine ' SEEPAGE PITS I I Depth Size Number R SUMPS !1 Distance to nearest: Well Foundation i Property Line f DISPOSAL PONDS ❑ I� 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 SanJoaquin Local Health District. I i f Home owner or licensed agent's signature certifies the foil "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." Tb&A (;cant must c 19r all re uire ins ions. Complete-drawing on-reverse Signed X Title:.....__ Date: , a= FOR DEPARTMENT USE ONLY Application Accepted b Date %:P\ �� Area I l $ Pit or Grout Inspection ii Date Final Inspection by ` Date Additional Comments: �� a C7 Stk 466-6781 ❑ Lodi i" 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 n Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 24 Stk., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED cK H RECEIVED BY DATE PERMIT'NO. a EH 13-24 IREV.t/N 5) ��V "E"�c�� ]� Lk EH 14-26