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t -S APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephohe (209) 466=6781 PERMIT EXPIRES i'YEAR FROM DATE ISSUED J (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. f c Job Address ] City Lot Size�D)(41_50M Owner's Name C r Address Phone _ t t Contract0r W 'h L h1)L.L- c-O&L.S F Address SQ to J License No. � Phone IS(- 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 FO AGRICULTURE WELL OTHER-WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE CTION SPECIFICATIONS D Industrial ❑ Open Bottom ❑ Man Dia. of vation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications l ('l Public ❑ Other ❑ Delta Depth of Grout,Seal Type of Grout _, i 1 Irrigation —Approx. epth I,I Eastern Surface-Seal Installed by};: Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter •""R ""Sealing-Material (top 50')— Depth ° Filler Material I8elow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 R[PAIR/ADDITION E I DESTRUCTION ptrc system permitted if public sewer is '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 s SEPTIC TANK ❑ Type/Mfg r�+r'1�C�f�t/`� Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line 1 9 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance'to nearest: Welt -4� `Foundation - -Property-Line— --f { SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: -Well-_- — -FoundationProperty Line ` DISPOSAL PONDS ❑ r 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 intheperformance 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 ce i ies 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- ti&nJaw Californi The applica t t c for lire ired pe lete drawing on reverse side , Signe Title: Date: j " FOR DEPARTMENT USE ONLY Application Accepted by Date� 1 ' Area Pit or Grout Inspection Date Final.Inspection by Data 1� s 8� Additional Comments: ✓1 t J-'� Co G' C] Stk 466-6781 0 Lodi 3M-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6395 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"e ""SASH "RECEIVED BY --DATE PERMIT NO" ~ Y INFO ` +.EH 1324(Rev.ii N 5) I `4 EH 14-29 G L •.