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l APPLICATION FOR PERMIT r + SAN JOAnUIN LOCAL HEALTH DISTRICT j. 4 1601 E. HAZEL T ON AVE., STOCKTON, CA I� SSP 3 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVrRpNM, NU I, ih (Complete in Triplicate) PERA41T j ES VECfALTN " Application is haieby made to the San Joaquin Local Health District for a permit to construct and/or install.the work herein described. This application is I 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., I � ,,J'D,3 .J. C/ 1..�/may CityJ� ./tf Lot Size PM Job Address Owner's Name Address3�3 "G Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: p ;'NEW WELL Ll WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 1 95-15'omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications w l'! Public Cl Other'L Cl Delta Depth of Grout Seal Type of Grout _ I I Irrigationi_Approx. Depth I i Eastern Surface Seal Installed by - i Repair Work Done [2Type of Pum` p -✓!�� H.P. State Work Done Well Destruction ❑ Wel[Diameter d Sealing Material atop 50') Depth Filler Material lBelow 50') TYPE OF SEPTIC.WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I 1 Mo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence- Commercial Other Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ TypeA fg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well foundation Property Line f LEACHING LINE ❑ No. &?Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I i Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have pfeparedithis 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. r 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." Contractor's 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." } The applicant m t call for a r ired inspect; ns. Complete drawing on reverse side. i lee I Sign Title:� i�sr1/l�/� J'�ii� Date: ..2� FOR DEPARTMENT USE ONLY Application Accepted by �. !t�Z] Date �V 0 Area V Pit or Grout Inspection by ! Data Final Inspection by Date 'h. Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: En"ironmental 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. tNFO +.EH 13-241REY.1in5) ��-7 f"y EH 14.29