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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1601 E. HAZELiON AVE., STOCKTON, CA Telephone (209) 466-6781 y + 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 r [�� ('t� ;,�i� City Lot Size PM { Owner's Name a � GO5 e, _ Address �� Phone Contractor Address P61 60k NIL License No. ? Phone _Knl TYPE OF WELL/PUMP: NEW WELL ❑ j:v.,,WELL REPLACEMENT ;❑ I DESTRUCTION ❑ '"PUMP INSTAL ATION_'0' SYSTEM RE�AIR ❑ OTHER ❑ {J -W DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES : DISPOSAL FLD. PROP. LINE I 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 Weli Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 1 Specifications ❑ Public ❑ Other 3 ❑ Delta Depth of Grout Seal Type of Grrlut I ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump; H.P. State Work Done ? Well Destruction ❑ Well Diameter s Sealing.Material [top 501 Depth FillerMaterial {Below 501 ? _ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION IDINo septic system permitted if public sewer is p/ "'r ; available within 200 feet.) installation will serve: Re idence ^Commercialy Other 71 ! Number of living units; Number of i1pdroomi, ` Character of soil to a depth,of 3 feet.- r" Water table depth SEPTIC TANK ❑ Type/Mfg „" Capacity /- i No. Compartments ° t PKG. TREATMENT-PLT:--0 -•^- -� -- p/{ethod of Disposal < - Distanceto nearest: Well Foundation Property Line LEACHING LINE P" & Length of lines Toyl length/size f9 4 FILTER BED ❑ Distance to nearest: i iWell Foundation, Property LineL� -4, } t SEEPAGE PITS ❑ Depth Size- —Number "Number r SUMPS 'i `Distance to nearest: ' Well _ �1 66ndation ' ` .Property Line DISPOSAL PONDS ❑° I a s _ I hereby certify,iha 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." l The applicant must call for Irequired inspections. Complete drawing on reverse side. 1 SignedTitle: ✓Lr Date: 'FOR DEPARTMENT USE ONLY Application Accepted by Date Area Lo } Pit or Grout Inspection b =Date Final''Ins pe Y pection by Date / CA Additional Comments: _ ' ❑ Stk 466-6781 �•.❑ Lodi 369-3621 NF❑;,Manteca -823-7104 ❑ Tracy 135-63385 Applicant'-',Return all copies to:Environmental Health Permit/Services 1601 E,.Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE! INFO AMOUNT DUET AMOUNT,,REMITTED CASH CK RECEIVED BY s DATE PERMIT'NO. EH 14-28 +EH 13-24(R&1/13 s)