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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit 10 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. Job Address City Lot Size PM Owner's Name Address Phone Contractor Gnphri nQ 2111110 _ Address License No.3090 1 ; .---Phone – TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR IX OTHER ❑ DISTANCE-TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �- ~ INTENDED USE J TYPE OF WELL ry PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i'f Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I 1 Irrigation —.-Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done X2 Type of Pump H.P. State Work Done I)l I 1 rpj)a i r Well Destruction ❑ Well Diameter Sealing Material (top 501 �^ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.( O Installation will serve: Residence_ Commercial_ Other a Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Wate6able depth SEPTIC TANK ❑ Type/Mfg Capacity No. Comp��rt©t Bents PKG. TREATMENT PLT. ❑ Meth-d ofViaa Distance to nearest: Well Foundation Property Line ENI "n i n LEACHING LINE ElNo. & Length of lines Total length/size D .�VIRC— M_ ` FILTER BED El Distance to nearest: Well Foundation Property Line SEEPAGE PITS i 1 Depth Size Number SUMPS Cl 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 Di§trict. 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 employ any person in s'uch er as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: c rt 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 Califor The applicant mu all r uired inspections. Complete drawing on reverse side. Signed X Title: Bkpr Date: 4 ORPARTMENT USE ONLY Application Accepted by Date 'FOLD r Area 147 Pit or Grout Inspection by Date Final Inspection hv� l� Date E —S"T Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH *.EH 13241REY. /H55 `r�y EH 14-29