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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PERMIT N0. 1601 ETelephonON(209).466067gON, GA p ; DATE ISSUED J/el � PERMIT EXPIRES I YEAR FROM DATE ISSUED J ' (Complete in Triplicate) l the rein Application is hereby lmade otoithe madeninocompliance withlSanth DJoaquin Countyistrict for a pOrdinancecNost549tfordsewage sorlNo. 1862rfor ewell/pump described. This application and the Rules and Regulations o the San Joa u'n Local Health District. O ubdivision Name Job Addres hone Address _ p s Owner's Name l Phone License No. Contractor's In. _ p TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 0 lr` 'XJ OTHER, ❑ Vim' PUMP INSTALLATION ❑ SYSTEM REPAIR PROP. LINE 1 SEWER LINES DISPOSAL'FLD. ^. DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS O FOUNDATION AGRICULTURE WELL _ � L CONSTRUCTION SPECiFICATIONS INTENDE�'l1SE. TYPE OF WELL PROBLEM AREA Dia of Well Excavation Industrial t (J Open Bottom ❑Manteca �'� ❑Tracy .�Dia. of Well Casing ❑ Domestic/Private i •Q.Gravel Pack ,:. „4,,,,�..��/ ❑ Public [�Other v ..:r ❑Delta Type of Casing V Irrigation Approx.,.r ❑Eastern [ Specifications Depths s, z. " '�epnth o`G. t f _r Cathodic Protection Depth of Grout�Seal i �V ❑Geophysical fi Type ofGrout" - - 1 ❑Other Surface Seal Installed by C T e�of-Pump--""'- State Work Done j Repair Work Done G yp f Sealing Material (top Well Destruction ❑ Well .Diameter Filler M _ aterial (Below 50') Depth {- q No septic tank or seepage pit permitted if public sewer is TYPE OF SEPTIC WORK:' NEW INSTALLATION REPAIR/ROOT yION ❑ ( e available within 200 feet.) Installation will serve: Residence i Commercial Other 1i -� / Number of rooms size _j &<_, . _ o Yr Number of living units: a Water table depth Character of soil to a depth of 3 feet: J Capacity No. Compartments SEPTIC TANK 2n-- Type/Mfg r Capacity Method of Disposal i f PKG. TREATMENT PLT. ❑ Type/Mfg r Foundation Property Line �j ( '`. /Q SEWAGE SYSTEM .Dis.tanceo nearest: llellzi e DESTRUCTIONs Q X .,..,! A Total length size f LEACHING LINE [� No. & Length of lines i Property Line FILTER BED ❑ Distance to nearest: Well O ! - Foundation If Depth Number ! SEEPAGE PITS Sizer Property Line SUMPS �� o- Distance to nearest: Wel} <�S 4 Foundation DISPOSAL PONDS ❑ I hereby certify that I haver prepared thisreguationsaof then 5anhJoaquinwLocalork ,Heallthll be dDistrict. one in ccordannc with San Joaquin county ordinances, state laws, and Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this € performance of the work for which � permit shiring orshall subn�ontractingnsignaturelcertifiesnthe following: eIscertifyubject tthatrinatherils cPmpensation laws-of California. Contractor'sn laws of California." this permit is issued,yI.shall employfpersons subject to workman's compensatio /P�verse side The applic must cal _for 11 required inspections. Complete drawing.gn . Date y / Title: tv/ �J Signed X FOR DEPARTMENT USE ONLY Area �_ ❑ Stk 466-6781 t Application Accepted by Lodi 369-3621 Additional Comments: Date Z5_Manteca 823-7104 pit or Grout Inspection Date ❑ Tracy 835-6385 Final Inspection by to: Env'ronmental Health Permit/Services 1601 E, Ha elton Ave., P.O. Box 2009, Stk! CA 95201 Applicant - Return all copie FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE 3PE I N D INFO � - lJ4 f 10/82 540 I EH 13-24 REV. 10182 14-2b