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FO APPLICATION FOR PERMIT P` SAN JOAQUIN LOCALMEALTH DISTRICT ' 1601 E. HAZELION•41E_ STOCKTON, CA �. % •; ++ Telephone {209) 466-6781 `f ref PERMIT EXPIRES TYEAR FROM DATE ISSUED r+ . (Complete in Triplicate) ��`&� y.� y Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.Thisjapplicatton 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. 41 Job Address "`f a City " "Size PM Owner's Name Address' 5e ys1 4 Phone ^" Contractor Address Z�icense No. _hone 4 L4 no tos TYPE OF WELL/PUMP: N W WELL ❑ WELL REPLACEMENT C] DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 17 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES f DISPOSAL FLD. PROP. LINE Vin 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 FI Public ❑ Other ❑ Delta Depth of Grout Seal ype of Grout _ I I Irrigation --Approx. Depth I 1 E tern Surface Seal Installed by Repair Work Done e/Type of Pump �� H.P. � _ --- State Work Done 4&t 4 Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I l DESTRUCTION I l INo septic system permitted if public sewer is available within 200 feet.) �1 .. Installation will serve: -Residence— Commercial�—''—l9ther •—Number of living-units: -Number of-bedrooms Character of soil to a depth of 3 feet: t Water table depth SEPTIC TANK ❑ Type/Mfg. Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING`L-INE-'.. k��Cl, 'No. & Length of lines l Total length/size FILTER BED :k ❑ Distance.to nearest: Well a Foundation Property Line SEEPAGE PITS I I Depth Size 'r Number ' SUMPS ❑ Distance to nearest t t Well, y Foundation Property Line DISPOSAL PONDS ❑ I hereby certify I have pre ed chis application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and retions of the San aquin Local Health District. !' Home(,- or licensed agent's si nature certifies t following: "I certify that in the performance of the work for which this permit is issued, I shall not emplorson in such manner as to becomes iect t work comps atian laws of California." Contractor's hiring or sub contracting signature certifillowing: "I certify t t in the or n t w f r wh'ch is permit is issued, I shall employ persons subject to workman's compensa- lion isalifornia."Theamust c i required i spe m on r verseSigneate: - FOR DEPARTMENT USE ONLY Application Accepted by Date � Area _tA Pit or Grout Inspection by Data Final Inspection by Data �Z�'3rtf Additional Comments: ❑ Stk 466-6781 ❑ 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 k FEE AMOUNT DUE OUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. , INFO CASH s + EH 13-241REV.t/x51 EH 14-26