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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 —3 4 y-`lif� City S Lot Size/�(\�I lS PM Owner's Name Q' 15 Address Phone Contractor '�tR�"�t `� L,"dress �d �`. icense No. Phone TYPE OF WELL/PUMP: - - NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 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 ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed try Repair Work Done ❑ Type of'Pump H.P. — State Work Done IJS Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION STRUCTION ❑ Mo septic system permitted if public sewer is 6 available within 200 feet.) Installation will serve: Re idence 1�Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: pjm) J Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE N;--1go. & Length-of lih4s 0 Total length/size FILTER BED ❑ Distaa to nearest: Well Foundation 440 Property Line --�t�L►L c �r,�+F �. SEEPAGE PITS 0-1�0epth ya _Size Number SUMPS >�istance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 5uIAA go hereby certify that I have prepared this application and that the work will be don4 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."Contractor's hiring or sub-contracting signature cert'les the following: "I c fy that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion la of California." The applicanN II for all quireA�sp-cths. Co to wing on r erse side. Signed Date: y F R DEPARTMENT USE ONLY Application Accepts" y V w Date 614 Area—019 419 Pit or Grout InspecDate ts by Final Inspection by Date Additional Comments: ❑ Stk 4664781 ❑ 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 RECEIVED BY DATE PERMIT NO. INFO + EH 13-241REV. EH 14-26