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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT N4 ' T AVE., TOCKTON, CAsgia, "CN 1601 E. HAZELTON ON �J 0� Telephone (209) 466-6781 S PERMIT EXPIRES 1 YEAR FROM DATE ISSUED tw� ,�I1F-NR�I��'� a tCom �OS plete in Triplicate? �� t F lth District for a permit to construct and/or install the work here described. This application is Application is hereby made to the San Joaquin Local Hea o. 549 for sewage or No. 1862 for welllpurnp and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance N Local Health District. Job Address od so r {}w- City Lot Size PM r Owner's Name Address _ �-�-- Phone C `� n Contractor Address pL[cense No. Z-Phone�� TYPE OF WELL/PUMP: NEW WELL ❑ WELC REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR X OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 171Manteca Dia. of Well Excavation Dia. of Well Casing )(Domestic/Private ❑ Gravel Pack [Tracy Type of Casing Specifications ['1 Public ❑ Other P'Delta. Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth ° .l.l Eastern ` Surface Seal installed by - Repair Work Done P' Type of Pump go."V= H.P. State Work Done Well Destruction ❑ Well Diameter .'Sealing Material [top 501 Depth Filler Material (Below 501 -- d TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION LI DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) k' Installation will serve: Residence_ Commercial— Other , [ Number of living units: Number of bedrooms * 1 F Character of soil to a depth of 3 feet: Water table depth (>SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Iq PKG: TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines F Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i I I SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ Distance to nearest: ,Wel! rte' Foundation Property Line DISPOSAL PONDS d' �� r{'" . 1 f "f 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 Di§trict. F 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'Calif6r6ia." Contractor's hiring or-sub-contractirtg-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 must L41ffor all required i spections. Complete drawing on reverse side. Signed ? Title: 404_414 - Date: /d r — r- f FOR DEPARTMENT USE ONLY t � i Application Accepted by Date � ' Area Pit or Grout Inspection by Date Final Inspection by Date Z= �a `/ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all c pies to: Environmental Health Permit}J/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMIT TE6 "GASH RECEIVED BY DATE PERMIT'NO. INFO (,, ..EH13-241REV.1/"5l �� L�. EH 14-28 / _,