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APPLICATION FOR PERMIT �k I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466.6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to the San Joaquin Local Health District(Complete In Triplicate) 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 Job Address /O 00 N1 CitySMW QQ//�� ► c�,6 Owner's Name eRc�( � ! [ ¢ Address 7 �-/L�Q:(� Lot Size 70j4C/► PM/Ij/V61.4� Contractor � ,L � 7 Phone X TYPE OF WELL/PUMP: Address �f-�? ,WELL ❑ License No./ NEWOZ.t�_Phone b�j��k PUMP INSTALLATION ❑ 'WELL REPLACEMENT ❑ REP DESTRUCTION ❑ � SYST DIS ST: SEPTIC TANK 7IDO ! IR ❑ OT ER FOUN N SEWER LINES DISPOSAL FLD. N A �� AGRICULTURE WELL PROP. INTENDED USE TYPE OF WELL OTHER PITS/SUMPS / /4 \ ❑ Industrial PRO REA CO ION SPECIFICAT ONS ❑ Open Bottom ❑ Ylaxam O� ®'bomestic/Private ❑ GravWell Excavation \ ❑ Public ❑ Tracy Dia. of Well Casingea N lQ- Other JV __ /� Type of Casing ❑ Irri R Delta Depth of Grout Seal Specifications App Repair Work Done — rox..Depth ❑ Eastern Surface Seal Installed by Type of Grout 4./ A- ❑ TYpe of Pump' H P Well Destruction ❑ Well Diameter State Work Done -- Sealing Material (top 50') Depth Filler Material(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTI Installation will serve: Residence ON El (No septic system permitted>if public sewer is V ON Other available within 200 feet.) Number of living units:_ - Number of bedrqoms Character of soil to a depth of 3 feet: U/ �— SEPTIC TANK _ / � " Type/Mf9 z Water table depth 0 � PKG. TREATMENT PLT.❑ /A Capacity / V No. Compartments Distance to nearest: WellMethod of Disposal L [ Foundation Pro LEACHING LINE perty Line /6o No. & Length of lines d j� FILTER BED AoI4 ❑ Distance to nearest: Well Total length/size YW Foundation SEEPAGE PITS AJ14 ❑ Depth — property Line ' SUMPSSize ti/14 ❑ Distance to nearest: Wll Number DISPOSAL PONDS jU e ❑ Foundation --__ Property Line I hereby certify Mat I have prepared this application and that the work will be done in accordance with San Joaquin rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: county ordinances, state laws, and r employ any person n such manner n to become subject ll workman's compensation 9� "I certify that in the performance of the work for which this permit is issued, I shall not certifies the following laws of California."Contractor's hiring or sub-contracting signature g:"I certify that in the performance of the work for which this permit is issued, I shall employ tion laws of.California." The applicant must call for all required inspections. Complete drawing on reverse side. p y Persons subject to workman's cornpensa Signed Title: J �/ Date: 5/ Application Accepted by FOR DEPARTMENT USE ONLY p Pit or Grout Inspection by Date Area I by' by Date Additional Comments: Final InspectionDate ❑ Stk 466-6781 ❑ Lod it ` Applicant- Return all copiantca es to; Environmental He❑altnh Peemt� ry71 ��' ,IOD ✓!!/1y ❑ Tracy 835_ ices 1601 E. Hazelton Ave., P. Box Zppg, Stk., CA 96201 FEE AMOUNT DUE INFO AMOUNT REMITTED CK « EH 13-24(REV.ves) CASH RECEIVED BY bA E, PERMIT'NO; EH 1428 D 9d ..— �