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z APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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-desc6ed. 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. ' 1' Job Address ) 10 J -ye,- City c ��vLot Size PM Owner's Name _L e e- R D v AJ Address 1 �o S CJ , S 60 �/ !f+� -A 1/e—, Phone i f Contractor �- Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ BOTHER ❑ DIST TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.- P INE I' FOUNDATION —' .AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE OF WELL PROBLEM AREA CONSTRUCTION SPECIE{ IONS i' ❑ Industrial ❑�Gravel Botto ❑ tanteca Dia. of WekLEx avation Dia. of Well Casing Domestic/Private ❑ Pack. ❑ a of Casing Specifications M Public ❑ Other Q elta D`eth-of Grout Seal Type of Grout I I Irrigation w _..Approx } I I Eastern Surface Seams I~ I�ns'taaIIed-by Repair Work Done a of Pump H.P. State Wor Weli Destruction ❑ Well Diameter Sealing Material Itop 50'1 DepthFiller Material IBelow 50') a 4 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION i.I DESTRUCTIO I (No septic system permitted if public sewer is available within 200 feet.) I V� Installation will serve: :Residence P!7�r Commercial_ Other Number of living units: Number of bedrooms F4 Character of soil to a depth of 3 feet: Water table depth ' SEPTIC TANK ❑ Type/Mfg. Capacity No. Compartments l PKG. TREATMENT PLT- ❑ Method of Disposal r Distance to;nearest: Well ,Foundation Property Line T 1 we j i LEACHING LINE ❑ No. & Length of lines Total length/size y FILTER BED Ll Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth I Size Number SUMPS L) Distance to nearest: Well Foundation �.. Property Line DISPOSAL PONDS ❑.. n i r. I hereby certify that I have preparbd 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 rformance of the work for which this permit is issued,1 shall employ 3 " V pe p p y persons subject to workman's compensa- tion laws of California." a I The applicant must call for all required inspections. Complete drawing on reverse side. Signed X j ,eTitle: 4'LtJ•��1r� _ Date: e VM FOR.DEPARTMENT USE ONLY , Application Accepted by + Date """`� Area Pit or Grout Inspection by _ Date Final Inspection by Date Additional Comments: �- :i ❑ Stk 466-6781 ❑ Lodi 369-3621:. ❑ Mantect ❑ Tracy 835-6385 Applicant - Return all copies to: Environm ntal ermit/services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CK F1 RECEIVED BY DATE PERMIT'NO. 3 ♦ EH 13-24(REV.tike) �� EH 14-26 1