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F 9 �. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1601 E. HAZE T ON AVE„ STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED j (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. IB62 for well/pump and the Rules and Regulations of the San Joaquin i Local Health District. ' Job Address - _29-2-0 4A7�i�L-0v, 2� City Al Lot Size PM Owner's Name 1-! /E eQn Address J7// LcJ, 49 --�N.M2 1-7- ]7i2 Phone rS -- 42-8 Contractor F'L0EQ dtJrW.?a Address_�7_ �J , ,. , No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ a PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION GRwCU-L-TU-RE WELL ._." _.. OTHER W LLQ �- PITS/SUMPS INTENDED USE TYPE OFWELL PR08 EM-ARE4 CflNS1RUCTlON SPECIFICATIONS ❑ Industrial ❑ Open Botiom ❑ Mari ca :Dia. of Well Excavation Dia. of Well Casing . ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public FI Other " '- (_1"De Depth of Grout Seal Type of Grout _ I I Irrigation --Approxi Depth Eastern Surface Seal Installed by . Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diamet Sealin Material (top 501` : - Depth _ Filler Material 18elow 50' , 1 D(I TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is r available within 200 feet-) Installation will serve: Residence� Commercial_ Other Number of living units: Num er of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type_/MfgCapacity No. Compartments PKG. TREATMENT PLT. ❑ I 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 SEEPAGEf PITS 11 Depth Site Number OSUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 District. 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, l shall not employ any person in such manner as to become subiect to workman's compensation laws of California Contractor's 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." ? The applicant must call for all required inspections. Complete drawing on reverse side. Signed X - _Title:= � Date = FOR DEPARTMENT USEONLY Application Accepted by Date Area ] Pit or Grout Inspection by Date Fina! Inspection by / Date J l Additional Comments: 44 ofto/ ❑ Stk 466-6781 ❑ Logi/369-3621 1-1Manteca823-7104 LJ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEI INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. r.EH 14.241REV.1/n51 � _A1bC> EH 1428 p