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i APPLICATION FOR PERMIT &• �� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 s, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r 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 welUpump and the Rules and Regulations Of the San Joaquin Local Health District. Job Address X550B�.LRt/✓O City - _ Lot Size PM Owner's Name :e c Address 51f�ffo957 Phone 3 Contracto -fro ,140 ddress /*,V-1 icenseNo.-�A Phone �4-s TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P. LINE FOUNDATION AGRICULTURE WELL OTHER WEL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA 4WWrCATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, xcavation Dia. of Well Casing t ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public ❑Other Delta Depth of Grout Seal Type of Grout I I Irrigation _ App'rox. Depth I I Eastern Surface Seal Installed by _ Repair Work Donee❑ rType of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 v" Depth Filler Matedal 'Below 509 TYPE OF SERYIC WORK: NEW INSTALLATION I AI REPR/ADDITION I DESTRUCTION I I (No septic system permitted if public sewer is �. v available within 200 feer.f O I Installation will serve: Residence_ Commercial-�10� Other - t Number of living units: _ Number of bedrooms - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 05 Type/Mfg Capacity 049 /No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal v" Distance to nearest: we(Til-IM" Foundation Property Line 1) LEACHING LINE ❑ No. 8 Length of lines y .firs Total length/size 1T" j 4 FILTER BED ❑ Distance to nearest: Well Foundation Property Line .P 1 SEEPAGE PITS ®4 Depth .?S Size Number y (y SUMPS ❑ Distance to nearest: Well Foundation Property Line l! DISPOSAL PONOS ❑ I hereby certify that I have prepared 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 Or3trict. t 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 i employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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 employ persons subject to workman's compensa. tion laws of California." r/ tThe applicant must call for allui� inspe 'ons. Complete drawing on reverse side. a d3/s tr � Saned.x�f 7Na: e�7G�_w6.e Date:_ 9 OR DEPARTMENT USE ONLY I Application Accepted by l Date a' `? Area619 ! Pit or Grout Inspection by 1l'+� Date t inal Inspection by Date.-3 Additional Comments: ❑ Stk 4666781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-6385 . • Applicant- Return all copies to: Environmental Health Permit/Services 1607 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 F ��r)V EE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. Cr IF ' •.EH 13-1 IREV.1/x31 /'] D,v—/� EH 14111