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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZELTON AVE„ S70CKTDN, CA PERMIT NO.73 / �� Telephone (209) 466-6781 DATE ISSUED PERh1IT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in Triplicate} 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 f the San .Joaquin Local Health District. Job Address Subdivision Name. I Owner's Name APA Address Phone. Contractor's Name r' License No. fl:-"7�/ Phone � �3. TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL-REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION-•❑__SYSTEM REPAIR ❑ -OTHER U �. DISTANCE TO NEAREST: 'SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP, LINE 1 FOUNDATION AGRICULTURE WELL !OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I Industrial Open Bottom Manteca Dia. 'of Well'Excavation Domestic/Private { LYS i. ❑ Gravel Pack ❑ Tracy ( Dia, of -Well Casing ❑ PublicI.l : ❑ Other ❑ Delta .' Type of Casing Ll Irrigation ' t' Approx. ❑ Eastern Depth � Specifications ❑Cathodic Protection t "Depth of Grout Seal ❑Geophysical Type of Grout Other k Surface Seal Installed by i Repair Work Done ❑ Type of Pump H.P. ,State Work Done Well Destruction ❑ Well Diameter Sealing Material](top Depth Filler Material ;(Below 50') - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION j;40 (No septic tank or seepage pit permitted if public sewer is "� b available within 200 feet.) Installation will serve: Residence i—Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: 5 �� Water table depth SEPTIC TANK Type/MfgCapacityNo. Compartments �+ PKG. TREATMENT PLT, ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ❑ Distance to nearest: Well _ Foundation Property Lire DESTRUCTION ,S" r LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: , Well Foundation —1�Y Property Line _ SEEPAGE PITS ❑j Depth l4Size�" `� Number } SUMPS L�; Distance to nearest: Well ' Foundation Property Line DISPOSAL PONDS ❑ j [.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 licersed 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, compensation laws of California." 1 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 compensation laws of California." The applicant m t c 1 for r quired inspections. Complete drawing on reverse side. 39�� Signed X " Title: Date: *- FO DE ARTMENT USE ONLY y� Application Accepted by Area _�J ❑ StR 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection b Date ❑ Manteca 823-7104 Final Inspection by Date.° 3 ❑ Tracy 835-6385 Applicant - Return all copie to; Environmental Health Permit/Services 160 E. H el ton Ave., P.O. Box 2009, Stk., CA 95201 i FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE �3 _ INFO �{ '-� t 3 4 EH 13-24 REV. 10/82 10/82 500 14-26