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t APPLICATION FOR PERMIT SAN JOAQUIN•LOCAL HEALTH DISTRICT 1601 E. HAZELION AVE., STOCKTON, CA. -Telephone {209} 466-6781 • i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED „ + iComplete 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. " �,r f N �2�kAV S� n ��.- •.? •" ' *. rig.; <....' .. Job Address o� �'^ U� ` i >l " �1ie City 7�� Lot Size PM Owner's Name arJ��UEr ��MASV fl? AddressPhone• " . d Contractor Address License No.i;jZ :iv`�Phone --FYPE-OF"WELL'/PUMP ----NEW-WEL-t-1—'—WELL-REPLACEME'W ❑ DESTRUCTION C PUMP INSTALLATION ❑ SYSTEM REPAIR ID OTHER C DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE `-FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS {�! INTENDED USE a TYPE OF WELL PROBLEM AREA CONSTRUCTIONiSPECIFICATIONS ❑ Industrial ❑ 8peh Bottom `ti ❑ Mu rfteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel P.d C Tracy Type of Casing Specifications j O Public ❑ Other C 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 Stop 501 I i Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLAM EPAIR/ADDITION C DESTRUCTION ❑ Mo septic system permitted if public sewer is t %. r•t i ;•available within 200 feet_) Installation will serve:,Residence, Commercial ^' ther if Number of living-units: f t t _� Nu1•rrber•ot�bedrooms Character of soft to a depth of 3 feet: A - _ Water table depth S SEPTIC TANK _•__,f_Type4Mfg 944-1 I Capacity d-Lrb No..Compartments 17> PKG.TREATMENT PLT:- �`' 1 Method of Disposal 3 y Distance,to nearest: Well, Foundation Property Line ] LEACHING LINE °'No. &Lfngtti of°lines (1� ' t Total lengthlsize 'd .t�t FILfiER;j3E3 i ' ❑ "Distance to nearest: —•Well Foundation I Property Line SEEPAGE P17$�j ❑ Depth ^~ �"" iia _ I Number ? I SUMP,;; 11DistanC d nearesi:'-�;,t/ll@II :y Foundation Property Line i DISPOSAL PONDS ❑ i I hereby certify that I have prepared thisrapplication'and'ihat the work will be done in accordance with San Joaquin county ordinances„state laws, acid rules and regulations f the•San Joaquin:Local Health District. s Homeowner or�7�vMesed agerif-s signature certifies the following: "I certify that in the perfomrance of the work for which this permit is issued, I shall not employ any persi in such manWer as to become subject to workman's compensation laws of California.”•Contractor's hiring or sub-contracting signature certifies the follovAg:"I cartify that in the performance of the work for which this permit islissued,I shall employ porsons subject to workman's convensa- tion laws of California�." ' The applicant must call f all r !red inspections. Complete drawing on reverse side. fi Signed X .ir�� \ Title:_ Date: 1` / FOR DEPARTMENT USE ONLY r - � Application Accepted by �, �� - _ � Date �— Area r Pit or Grout Inspection by \ �' Date Final Inspe'tion by� ��— Date Additional Comments: E ❑ Stk 466-6181 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835-63% Applicant- Return all copies to: Environmental Health Permit/Services 1601�azelton Ave., P.O. Box 2009, Stk,;CA 96201 FEE CK . . INFO AMOUNT DUE' AMOUNT REMITTED ASH RECEIVED'Si, DATE PERMIT ND. a EM 1428 ! v . 't,