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j 4 k - APPLICATION FOR PERMITZf 4� 0 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. FiAZEL i ON AVE., 5TOCKTON, CA - Telephone (209) 466-6781 / LeL 'r .4V I� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C 1 e- / ' (Complete in Triplicate) �tss I� ►'`� ''� li 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 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 1 Local Health District. LJobrAddress City ,Lat Size PM er's Name Address ' ' I Phone a'tractor - E Address License No. Phone TYPE OF WELL/PUMP: NEW WELL F-1WELLREPLACEMENT ❑ DESTRUCTION ❑ PUMP I h ALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES DISPOS 'E FOUNDATION AGRICULTURE W OTHER WELL PITS/SUMPS INTENDED USE TYPE 4F WELL PRO A CONSTRUCTION SPECIFICATIONS j E] Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing O Domestic/Private ❑ ack ❑ Tracy, pe of Casing Specifications 1` Pubther I� Ll Delta Dep f Grout Seal Type of Grout . I Irriglic n O..Approx. Depth I I Eastern Surface Senstalled by _ r Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth �` Filler Material (Below 501 dq TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTIO (No septic system permitted if public sewer is " available within 200 feet.) Installation will serve: Residence Commercial_ Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth � SEPTIC TANK LJ Type/Mr fg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Ii 1 Method of Disposal Distance to nearest: Well Foundation Property Line .i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line a SEEPAGE PITS I I Depth 'i Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl ,j 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."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, f shall,employ persons subject to workman's compensa- tion laws of California." I I The applica ust call for all required inspections. Complete drawing an reverse side. II' 7 Signed ` Title: �`'� Date: l` FOR DEPARTMENT USE ONLY, C Application Accepted by Date , �v�� Area p ,�J Pit or Grout Inspection b to Final Inspection by Date Additional Comments: 1 �U ! r 1� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy B35-638 Applicant - Return all copies to: Environmental Health Permit/5 as 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DULE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"IVO. +.EH 13-24(REV.1/K5) �"' 1 EH 14-28 —� II