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APPLICATION FOR PERMIT r�AYMEN 1 SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZELTON AVE., ST $1TON, CA Telephone I �' ' 9g 2 1 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED NVIRONMENTAL HEALTI-71 (Complete in Triplicate) r1rr1M1T1SFPV1(7 ' 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 of the San Joaquin Local Health District. City Lot Size PM Job Address Owner's Name Address Phone a Contractor Address License No. Phone I TYPE OF WELL/PUMP:: .NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ -. PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:-SEPTIC TANK` - SEWER LINES... .. DISPOSAL FL-D.=� PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/Sumps'", INTNOED USE F TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D I strial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F Domestic/Private D Gravel Pack- D Tracy Type of Casing Specifications 0 l'1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout - =- I 1 Irrigation Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done ❑ # Type of Pump _SLQ H.P. '1 - State Work Done/ ! �...° — ! Well Destruction ❑ Well Diameter w Sealing Material Itop 501 $ - Depth Filler.Material IBelow 50:1 - M -.T -OF SEPTIC WORK: NEW INSTALLATION I:i REPAIKIADOITION I 1. DESTRUCTION I i INo septic system permitted if public sewer is _ available within 200 feet.) .installation will serve: Residence Commercial— Other Number of living units': Number of bedrooms ; Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK D Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I - Method of Disposal n t Distance to nearest: 'Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS C I Depth Size Number L D Distance to nearest: Well Foundation Properfy L`in DISPOSAL PONDS ❑ t 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 certif"hat 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: "f certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of California." The applican us1 call for all re urred inspections. Complete drawing on reverse side. Signed X/` C - Title: Date: Aa T 3 fi FOR EPARTMENT USE ONLY Application Accepted by Date r Area 1 ` Pit or Grout Inspection by Date Final lnspection by Da Additional Comments: —Applicant 466-6781 — -❑-Lodi- 369-3621- -x =CO Manteca-823-7-104,- ❑ Tracy 835 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave-, P.O. Box 2009, Stk., CA 85201 xFEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO. INFO �. fKS � EH13 4fREV,1/851 q1D-Z EH 1428'