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#Y ' APPLICATION FOR PERMIT I UIN LOCAL HEALTH DISTRIC = SAN JOAO. , X ;� a 1601 E. HAZE-.3014)AVE., STOCKTON, CA SEP v f� Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED VIR()MEN A'4 . (Complete in Triplicate) FERMti�/SERvlCS' 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. - t� I 'City ize PM Job Address p l f � ' 4 Owner's Name Address `` _...! L—!`F �'� Phone Contractor t V Address tJ0 Z+ - License No.L 1 3�3 Phone4& v 7 if TYPE OF WELL/PUMP: NEW WELL ❑ ,WELL REPLACEMENT © DESTRUCTION C1 !! PUMP INSTA'LLA'TION ❑ � SYSTEM REPAIR,21 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1 k' ISPOSAL FLD. PROP. LINE FOUNDATION _ AGRICULTURE WELLl 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 ! 13 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing } Specifications r, t f`1 Public n Other ❑ Delta Depth of Grout Seal c Type of Grout € 1 Irrigation / Approx. Depth rl I1Estern Surface Seal.installed by - Repair Work Done C�' Type of Pump ��J H§PV "— state-Work.Done Well Destruction ❑ Well Diameter Sealing Material atop 50') t Depth A Filler Material (Below 50') l TYPE OF SEPTIC WORK: NEW INSTALLATION (:1 REPAIR IADDITION i I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other a 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 r Distance to nearest: Well Foundation Property.Line 1. 1. LEACHING UNE ❑ No. & Length of lines. 3� Total length/size" FILTER BED ❑ Distance to nearest: Well Foundation Property Line r Y •1 SEEPAGE PITS I I Depth Size - Number SUMPS ❑ Distance to nearest: Well Foundation r Property Line DISPOSAL PONDS Cl hereby certify that I have prepared this application and that the work will be done in fccoidance with San Joaquin county ordinances, state laws, and rules and regulations San Joaquin Local Health Diktrict. f Home owner or I' nsed agen signature certifies the following: " ertify that in the performance of the work for which this permit is issued, I shall not employ any pe on in such mann as to became su ct wo s ca pensation laws of California." Contractor's hiring or'sub contracting signature certifies thef (owing:" f certify th Pt't the part" J o fog+iD c this'per "-'issued';"I shalPemploy"persanssubjeCCtb workman's compensa s. tiorrJaws of California." The applic t must for r ired ins a on rev e Signed X v tle: Date: ��/" FOR EPARTMENT USE ONLY 4 Application Accepted by Date =_ Area Pit or Grout Inspection by Date Final Inspection by Date f" 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 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. INFO EH 13-Z4(REV.`i/n5) EH 14-26 f