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APPLICATION FOR PERMITO SAN JOAQUIN LOCAL HEALTH DISTRICT �—,,v„ 1601 E. HAZELTON AVE., STOCKTON, CA 1 , Telephone (209) 466-6781 ti.. ,, PERMIT EXPIRES 'I'YEAR FROM DATE ISSUED �+ ` (Complete in Triplicate) Y l;;_;,LT"r) NV1RCjr�h :�:A- C Application is'beleby made to the San Joaquin Local Health District for a permit to construct and/or install the wor '61% r�'bPL dt`lsj ptication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules an gu ations of the San Joaquin Local Health District. r Job Address / �-""` e' PM Owner's Name P.� Z, i Phone Contractor IWi_-' �ddress License No. Pho4 TYPE OF WELL/PUMP: NEK 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 U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public Cl her 171 elta Depth of Grout Seal Type of Grout14 _ I I Irrigation Approx. De h, 1, astern S if Seal Installed by_ _ F Repair Work Done Typo of Pump 1f H.P. State Work Done Well Destruction ❑ Wel! Diameter Sealing Material {top 50'1 d Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1-1 REPAIR/ADDITION I.I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) F Installation:will serve: 'Residence_I Commercial Other' Number of living units: i Number of be 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 ,T LEACHING LINE ❑ No. & Length of lines Total ten gth/size FITTER BED ? ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS 11 Depth Size , Number i SUMPS a L] Distance to nearest: Well Foundation Property Line h DISPOSAL PONDS ❑ 1 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 G ag 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 on in such man er as to be omeauN workman's compensation'laws of California." Contractor's hiring or sub-contracting signature certifies the (lowing:."I certif hat in th rma e. the work fo .which this permit is issued, I.shall employ persons subject to workman's compensa- tion laws California.' The appli nt m all re r ete drawing a v side. ' d (? � I Signed X Title: Date. _- k FOR VfEPARTMENT USE;ONLY j Application Accepted by Date Area `f �lifit�fit or Grout Inspection by bate Final Inspection by `� Date k Additional Comments: i t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK d RECEIVED BY DATE PERMIT'NO. + EH 13-26[REV."i�51 EH 14-26 ••J// ( /ar7FJ