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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE{, STOCKTON, CA ' Telephone{209) 466-6Mll PERMIT EXPIRES 1-YEAR'FROM DATE (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 Ryles and Regulations of the Sanoaqu" Local Health District. 49 ' `� Job Address _ ffacZ2 w �� ' CitYj '4 �G" 1 Lot Size .1--, PM-24 Owner's Name 7?R At R "0V-6R_ Address - Phone Contractor Address 1O License No.017T' �-Phone a ff . TYPE OF WELL/PUMP: -NEiN W..ELL.❑o<.. WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. -PROP. LINE �_- FOUNDATION_ .AGRICULTURE WELL_ OTHER,WELL. PITS/SUMPS ... INTENDED_U_SE_ _ TYPE OF WELL PROBLEM AR ,,�C EAONSTFLQCTION_SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel,Pack ❑ Tracy Type of Casing Specifications' ❑ Public ❑ Other I ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by . Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material {Below 50'! `� k - � U TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑;JNo'septic system permitted if.public sewer is T' y ..---1 available;within 200 feet.l. J Installation will serve: 3 Residence -Commerciafher Vii. a I " Number of-living units:� Number of bedFooms Character of soil to a depth of 31fee4: r$ wD 4- A >D$CJ'" Waterable depth SEPTIC TANK E'� Type%Mfg �'�� ` -� i� Capacity No. Compartments 1 PKG. TREATMENT PLT:❑ - z; ' `Method o1>6 9 rt E Distance to nearest: Well� Foundation: � Property Line ° Y LEACHING LINE IW No. &"L`er�gth 6f liri� '"" """" f Tatal:len�th/size^ E FILTER BED !❑ Distance to nearest: z Well ��d Foundation .?f Property Line 66 Azv s' s 3 l ,nom is 9 f SEEPAGE PITS ❑ -Depth t Size Number. ' f " SUMPS ' Distance to nearest: Well ouk tion t Fq Property Li6e ' DISPOSAL PONDS ❑ �'' -TA1 ,p 1 I hereby certify that I have prepared this application an1.d tha't-the work will be done in accordance with San Joaquin county ordinances, 'state laws, and rules and regulations of the San Joaquin Local Health 6iistrict. .l;� i Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the workifor which this permit is issued, I shall not r tis.--:----- � r, employ any person in such manner as to becor>,e-"subjecl-to-Wd—rkman's compensation laws of Califorpia;' contractor's hiring or sub;contracting signature certifies the following: certifyythat,ih�ihe performance of the work for which this permit is issued,1 shali.e pldy_( rsonB subject to vrorkman's compensa- tion laws of California." _ ' `'' R" I ♦ �. � i: -i The applicant must call for all required inspections. Complete drawing on reverse side. Signed K i Title: Date: FOR DEPARTMENT USE ONLY 14 Application Accepted by ° Date Area Pit or Grout Inspection by Date —Final Inspection by Datil Additional Comments: / { ❑ Stk 466-6781 Lodi 369-3621 ❑ Mantteca 823--11104 ❑ Tracy 835-6385 j. Applicant- Return all copies to: Environmental Health PerrnOServices 1601 E. Hazelton Ave., P.D. Box 2009, Stk CA 95201 FEEMOUNT DUE AMOUNT REMITTED CASHRECEIVED BY DATE PERMIT`NO.�: INFO - ' +EH 1324 4REV.V 8 5)