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s�. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA n Telephone (209) 466-6781 �sa�a-,- 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. I" L/7 7� Job Address I t/ 3Xy__7J4VSize ` ! /t 0-7 PM 1C.i4A AZA, w XOwner's Name Addres 0 Phone v1 N©1VF S Contractor Addres License Ne. Phone_ k7A /I/ TYPE OF WELL/PUMP: a 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 PS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC FICATIONS 0 Industrial ❑ Open Bottom ❑ Mantecaof Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ �Gelack yType of Casing Specifications l'l Public ❑ F1 Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by - Repair or ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Wel! Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION [] REPAIR/ADDITION ( I DESTRUCTION (No septic system permitted if public sewer is' X,available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 04 Water table depth �,aR SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line n t SEEPAGE PITS Depth 13 _Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ N I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,Istate laws, and I rules and regulations of the San Joaquin Local Health District., i ` 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 persaDji sn uch manner as to become subject to workman's compensation laws of California." Contractor s hiring or sub contracting signature certifies the folloZvmg: "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'15alitornia." cant must call for all,requirad ' s do Tete drawing on reverse side. Signed X ��...JJJ Title - - Date: FOR PARTMENT USE ONLY 1 Application Accepted by date �~` 1 Ar a Pit or Grout Inspection by Date Final Inspection byaXeex, G it 4 Additional Comments: 27 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Writeca 1323-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.'Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 # r INF AMOUNT DUE AMOUNT REMITTED CASH RE EIVED BY ( /9DA�TEE/ PERMIT*NO. t EH 13-241R ~' EV.riK5) �J� �— s f� V ! L / p 7 .Z9 EH 14.20 iii �[w 1