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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t �/� �°"ts� f ��17• 1601 E. HAZELTON AVE., STOCKTON, CA L•0�2 n�� ems, u s7t h pliW<< � Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED v-0 O>.� V t (Complete in Triplicate) Application is hereby made to the San Joaq lU 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. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. L1l Job Address City of Size PM . Owner's NerrlltY C��l�" '"- Address '"'r - p T Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM EPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION GRICULTURE VIL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM EA NSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Spec'tficad" ❑ Public ❑ Other ❑ Delta th of Grout Seal Type of Grout ❑ IrrigationJApprox. Depth ❑ Eastern Su Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 �1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is i available within 200 f t.1 Installation will serve: Residence_+ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Cepac' No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: WeII oun ion Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well /o-u dation Property Line n SEEPAGE PITS 0 Depth l Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 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." ) licant must call f r all required ' spe tions. Complete drawing on reverse side. Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted byDate -a` Area Pit or Grout Inspection Date Final Inspection by -`&-7( Date Additional Comments: I'llA_/VW11L G 1,1 1e_ ❑ Stk 466-6181 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazefton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE ! AMOUNT REMITTED CK RECEIVED BY DATE PERMIT•N0. ♦ EH 13-24(REV.1/13 5) f EH 11-2&