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"a. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR FROM DATE ISSUED (Complete in Triplicate) I 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. r l Job Address / 2 /�` City Lot Size _4&d PM Owner's Name Address �a / Phone Contractor Address ' ��_3 License No. 3 Phone f� TYPE OF WELL/PUMP: NEW WELL ❑ f WELL'REPLACEMENT ❑ DESTRUCTION ❑ f PUMP INSTALLATION ❑ . SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO.NEAREST: SEPTIC TANK r SEWER LINES DISPOSAL FLD. PROP. LINE FO< NDATION�tP AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE.OF WkL�,I?PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O OpenmBoftom ; ❑ II)! ka. a Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tra Type of Casing Specifications i'l Public ❑ Other ❑ Delt � Depth of Grout Seal Type of Grout _ I I Irrigation --Approx. DeR4h _ i`,I Easf�rri'�"'�' Surface Sealrall$dy'� Repair Work Done ❑ Type of Pump �I.. �–' H.P. State Work Done f Well Destruction El Well Diameter �it J1' I V Sealing Material Itop 50') Depth }`1 V,FOIer M iterial (Below 501 ' t. TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADbI-T40N FST40X_i-.1�o septic system permitted if public sewer is, ' 4 ✓ 'f..s t available within 200 feet.) f` l JJJ Installation will serve: Residence �l mercial Other Number of living units: _� /N/umber of bedrooms Character of soil to a depth of 3 feet: ��0 �. Water table depth , SEPTIC TANK ❑ Type/Mfg Q�f t Capacity_/��s INo. Compartmentsg t PKG.TfREATMENT PLT. ❑ /: l 'Method of Dispol;al Distance to nearest: Well/G4 Foundation Property.Line /4 I r LEACHING LINE No. & Length of lines 1 U i Total length/lize I r , r FILTER BED. - ❑ Distance to nearest: Well�6,R Fouri�lation_,//� f- Property Line � ,/0 3 :4 '�- / SEEPAGE PITS � Depth �n'>� Size _ Number SUMPS Cl Distance to nearest: Well i.Foundatibn Property Line �� l DISPOSAL PONDS ❑ I hereb}y certify that I have prepared this application and that the work will`'be done ira accordance with Sn Joaquin county ordinances; state laws, and f rules and regulations of the San Joaquin Local Health Di1trict. i f Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for�+hhich this permit is issued,'1 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 err( py perso�,s subject to workman's cor`€,pensa: I tion laws of California"' r The applicant t call f�quired is. Complete drawing on reverse std I Signed Title: tr Date: " FOR DEPARTMENT USE ONLY Application Accepted by � . tiJ dt_-r� F ,_ Date � A;rea Pit or Grout Inspection by Date Final Inspection by �a to — Additional-Comments:- 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy,A 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 160N.-,Hazalton Ave.; P.D. Box 2009;,Stk., CA 95201 CK A FEE INFO AMOUNT D�UE AMOUNT REMITTED CASH RECEIVED 13Y DATE PERMIT•NO. ♦.EH13.241REV.1/951 EH t4-28 r t` _