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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES /'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 Districts e� Job Address 1777 b _ City ..� Lot Size PM Owner's Name q �K'1 �3t�C '1 Address 1}� '�� Phone Contractor PLLRN14MC>J 1D1r11it" aaddress f'.0. Q( —License No. 3 ?.3 Phone �P7"36.5 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 11SYSTEM REPAIR ' OTHER !( DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation 11 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'] Public 17 Other LI Delta Depth of Grout Seal Type of Grout Irrigation _Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 } ti Depth filler Material (Below 501 _ TYPE OF SEPTIC WORK:- NEW INSTALLATION I 1 REPAER/ADDITION l 1 DESTRUCTION l I INo septic system permitted if public sewer is —� available within 200-feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms \ Character of soil to a depth of 3 feet: 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 ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ 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, an f rules and regulations of the San Joaquin Local Health Di1ttict. 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 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 applic call for all quer inspections.Complete drawing on reverse side.` , Signed X r .Glit.Gr� Title: Date: F. DEPARTMENT USE ONLY ( Application Accepted by w [_ _.Y.__„-i_, Date Area `�- Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi/369-3621 ❑ Manteca 623-7104 ❑ Tracy 836-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOU T DUE AMOUNT REMITTED CASH CK 41 RECEIVED BY JDATE PERMIT'ND. +.EH13-241REV.r/R5) , EH 14-26