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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 F (Complete 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. Job Address . _Gf_3 3 City Lot Size PM Owner's Name N UR r`S � JAddress q3 37 ,C– W_,4�.-LPhone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D -�_ DESTRUCTION D PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ CJV DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION r AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack D Tracy Type of Casing Specifications J f. ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type,of,Grout ❑ Irrigation ---Approx. Depth D Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction •❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION D DESTRUCTION (No septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence— Commercial_ Other r. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capaci No. Compartments ! PKG. TREATMENT PLT. ❑ ,]]��}} uED::xpni Method of Disposal Distance nN n Property Line LEACHING LINE ❑ No. & LengtpgVM t have expirea WithulL111.Total length/size FILTER BED ❑ Distance to ne r t� ii ly Uell� s &c@pccrgpp, t d ` Property Line , w�l�l SEEPAGE PITS ❑ Depth F @iwTG' 'L Number SUMPS fl Distance to nearest: Well Foundation Property tine DISPOSAL PONDS Cl 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, I shall not 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." , The applicant m t call or alE required inspections. Coriiplete drawing on reverse side. Signed _ � -^�� Title: Date: �� f !` FQR DEPARTMENT USE ONLY q Application Accepted by _ Date V Area Pit or Grout Inspection by Date Final Inspection by Dat Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 anteca 823-7104 ❑ Tracy 835-6385 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazekon Ave., P.O. Box 2009, Stk., CA 95201 L FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. + EH 13-241REV,1/B 5) EH 14-26 i