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APPLICATION FOR PERMIT 086-600 -6"l SAN JOAO,UIN LOCAL HEALTH DISTRICT � 1601 E. HAZEL—ION AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR'FROM .DATE ISSUED {Complete in Triplicate) i 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. 188662 for.well puumpand.the Rules and Regulations of the San Joaquin Local Health District. IPM —� ®d U City t ize Job Address - ( 4 Owner's Name ress Phone M Contrackor ress cense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT.0 i,DESTRUCTION`❑ II Pl3MP INSTALL'ATION'❑�'""� —SYSTEM-1�EPA1R ❑ "r '�"`�R��TFiER�❑ DISTANCE TO NEAREST:iSEPTIC TANK SEWER LINES DISPOSAPROP. LINE !� FOUNDATION AGRICULTURE WELL R WELL PITS/SUMPS J INTENDED USE TYPE OF WELL PROBLEM AREA CONS ION SPECIFICATIONS Dia. of Well Casi ❑ industrial ❑ Open Bottom El Manteca a. of Well Excavation d �►9 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing rSpecifications ❑ Public ❑ Other „� to Depth of Grout Seal Type of Grout- 0 rout❑ Irrigation ---Approx. De ❑ Eastern Surface Seal Installed by r Repair Work Done LJ Type of P p H.P. State Work Done i Well Destruction ❑ Well iameter Sealing Material(top 509 II Depth F Filler Material (Below 501 k TYPE OF SEPTIC WORK:, NEW INSTALLATION ❑1 REPAIR/ADDITION El DESTRUCTION ❑ (No septic system permitted if public sewer is ,� ih _ available within 200 feet.) Installation will serve: Residence '� Commercial_ Other ti h f V m J r Number of living units: r Number of bedrooms . Character of soil to a depth_ of 3 feet: � Water table depth Y t ¢ ¢ SEPTIC TANK ❑ jype/Mfg Capacity No. CompartmentsAF , ' i7 Y Method�o3i�osal. PKG. TREATMENT PLT. E- F Distance to nearest: Well Foundation (Property Line LEACHING LINE El No. &Length of lines ~' t Total length/size € FILTER BED 0 Distance to nearest: Well Foundation t j Property Line f SEEPAGE PITS ❑. Depth._ �� ize ` l Number SUMPS 3 D' Distance to nearest: Well- Q Foundation_t a Property Line DISPOSAL PONDS El j •� i II hereby certify that I hand prepared this application and that the work will be done in acc6rrdance with San Joaquin county ordinances, state laws, and i rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the-following: '1 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 becomesutiject to workman's compensation laws of California Contractor's hiring or sub contracting signature I 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 j tion laws of California." ti . ' The applicant must for I require ctions. Complete drawing on reverse side. '!) ' Signed Date:Title: i }� FOR DEPARTMENT USE-ONLY Area Date I' " Application,Accepted by ° �/ PP, 1. V Final Inspection by 2-? ?7' P t or Grout Inspection by Date Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca- 823-7104 ❑ Tracy 8354M8 Applicant- Return all copies to: Environmental Health Permit/Services 1fi01 E. Hazelton Ave., P.O. Box 2009,�Stk., CA 95201..._ FEE AMOUNT DUE AMOUNT REMITTEDCASH RECEIVED BY DATE PERMWN0. INFO �g / + EH 13-241REV.1/851 i i EH 14-28 - ,,.,_