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�._"4, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 1209) 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. 7L— Job Address ,1,,., City Lot Size . C.9"e PM Owner's Name 1, tf��t S ' Address Phone f � _ Contractor W h LTHALL C ddress S Q License No.��Phone `! TYPE OF-WELL/PUMP:` '' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS © Industrial ❑ Open Bottom ❑ Manteca of Well Excavation � Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack! ❑ Tracy Type of Casing Specifications ("1 Public n Other ❑ Delta , Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I 1 Eastern r Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. - i - r State Work Done Well Destruction 0 Well Diameter Sealing Material (top 50') Depth ' Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION is REPAIR/ADDITION STRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) - Installation will serve: Residence; mmercial_ Other r Number of living units: --I— Num bar-of-bedrooms Character of soil to a depth of 3 feet: Water table depth a SEPTIC TANK 1��Type/Mfg -0, �+ "'� Capacity �- Q_ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal q Distance to nearest: Well fpb Foundation �)IbProperty Line LEACHING LINE IiUNo. & Length of lines r !�� otal Isgth/size 470 FILTER BED , ❑, Distance to_nearest: Well A Foundation Property Line z— x F f SEEPAGE PITS' $4 > IX—Repth �� Size Co Number SUMPS I ❑ Distance to nearest: Well ..."tFoundation Property Line In 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 San Joaquin Local Health District. I a "r 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 , any person in such Mannar as to become subject to workman's comparisation laws of California." Contractor's hiring or sub-contracting signature Certifies following: "I a 'fy 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 fornia." t r The applicant m call for all equir ins ions. to drawing on r erse side. Data: J FOR DEPARTMENTUSEUNL f" Pr Application Accepted by / ' t z Date 5-- S Araa Pit or Grout Inspection by at IS"O Final Inspectionb - Y. Date Additional Comments: p- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma ca 823-7104 ❑ Tr y 835-6385 Applicant - Return a I copies Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT REMITTED CK RE DI1T PERMIT N4. INF / a EH 13-24(Rr;v.IVM-EH 14-26 fi