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�. ,. APPLICATION FOR PERMIT r .^M" SAN JOAQUIN LOCAL HEALTH DISTRIC k 1601 E. HAZ ETON AVE., S70CICTON, CA" Telephone (209) 466-6781 SEP PERMIT EXPIRES TYEAR FROM DATE ISSUED ODM NTAL HEALTH {Complete in Triplicate} PERMIT/ ERVI�F ` 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. City Lot Size PM Job Address Address `SL-� Phone Owner's Name t7 �/ Contractor ? -� Address lJ 1�3`0 ►License No. (3 �y Phone NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WELLIPUMP: SYSTEM REPAIR CK, OTHER ❑ PUMP INSTALLATIONz fSEWER LINES D15POSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS FOUNDATION AGRICULTURE WELL' _ OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing 11 Industrial'' ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications - � '7 a of Casing KDomesticlPrivate_,4 ❑ Gravel Pack ❑ Tracy - yp Type of Grout -- t1 " Delta' �Depih-of Grout Seal ll PtAblic, ❑ Other ' .-Approx. Depth t I Eastern Surface Seal Installed by 4 I i Irrigation 4�� State Work Done ! Repair Work Done [ Type of Pump . -- H.P. l Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 k N t 1 DESTRUCTION I I TYPE OF SEPTIC WORK: NiEW INSTALLATION l'I REPAIRIADDITIOavailable septic ailablew thin 200 feet't�ed i1 public sewer is i Installation will serve: Residence— Commercial_ Other (1 Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTkC TANK © Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ Property Line " Distance to nearest: Well Foundation Total length/size LEACHING LINE ❑ No. & Length of lines Property Line .,, w ❑ t ' Distance to nearest: Well Foundation FILTER BED � Number SEEPAGE PITS _ 1 I Ii,Depth Size Property Line SUMPS LlDistance to nearest: Well Foundation DISPOSAL PONDS ❑ ` I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordna'n�es�state-laws, and rules and regulations of the San Joaquin Local Health Diltrict. 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.beeome•subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature I 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 must c I fo all require�inspqctions. Complete drawing or erse side. Title: Date: Signed X A;;W= Y 9 � -w " Date Area Application Accepted by S rl p Date Pit or Grout Inspection by Final Inspection by .�- Date I Additional Comments: g ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK RECEIVED BY DATE PERMIT'NO. AMOUNT DUE AMOUNT REMITTED CASH INFO 1.EH 13-24 IREV,1/H 51 EH 1428