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APPLIQ�TION FORT PERMIT g SAN JOAQUfIaAMCAL.HEALTH DISTRICT 1601 E."HAZEL T ON AVE., STOCICTON, CA Telephone (209) 466JOW }rl :rj 42 � r - r.ri9� �.i %('� y+j '- �r ! i''f".. { i.:�' .'! !� r 1'�•? �`1x- °:j # "ri tri Y PERMIT EXPIRES1 ,�C1,f1 :, .,c rF:�?°:.�8 .. ,_I;,,t."aur t.if;� ,i}1'?`13 si?��''t.'��G1F71Q�2t:8lll �rkl7.IfC.�t��X•� .,�!��,l��t v�_11-.t e'::ftl�iiJ>ww.".?�E�ll<.st "_,, t' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein describ di Titi9 application is LrladBanrcoinpiiance With iSa4"_Jpaq'air+Cpurity:Ordinance'No.5A8 orsewageor;No;:1862"for.-well IOurnp.sand,thkiRules_arid;fiegulptiohs.of the,$an,Joaquin Local Health District s s., t FP�t.e�, lti s •`�ffse�ff. .�"SI_rT�.r tof1jC' 4`6'1.x% lr•' w�w s,1 51 ; ] M1 lr''1'1�1�•d :5� }(IY-.i� i'" Y ISY � Y.df ; i � Y � �;�� .-��' .,"yP ij 4. "i )t� kL f35�i 5 �' .�s Job Address 3 Lot Sire i ce` �Y PM...... Owner's Name .�A�� Address Phone 'Contractor's Name, -a License No. r Phone TYPE OF"WELL/PUMP:, NEW WELL ❑ : WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 'SYSTEM"REPAIR ❑ OTHER ❑ DISTANCE TO.NEAREST: SEPTIC TANK SEWER-LINES DISPOSAL FLD. T PROP. LINE �] FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE iOF WELL •PROBLEM AREA CONSTRUCTION SPECIFICATIONS - - .❑ Industrial ❑Open Bottom" "- ❑-Manteca 'Dia, of Well Excavation :Dia..of Well Casing {� ❑ Domestic/Private: ❑ Gravel Pack ❑ TracyType of Casing Specifications 1 .. C] Public El Other C1 Delta Depth of Grout Seal 'r Type:of Grout ElIrrigation __",..�4pprox:Depth ❑ Eastern Surface S r eat installed by Repair Work Done ❑ Type of Pump H.P. State Work^Done Destruction ❑ Well Diameter Sealin Material « Well Dest g al (top 50') 1- Depth Filler Material (Belo" 501 TYPE OF SEPTIC WORK: NEW INSTALLATION❑ :REPAIR/ADDITION DESTRUCTION ❑ (No septic,systepermitted if public sewer is - available hi ee • av 'abi wit 'n' feet.) Installation will serve: Residence�Commercial'_ Other Number of living units:� Number of bedrooms Y Character of soil to a depth'of 3 feet:' ti -(- ", Water table depth SEPTIC TANK ❑ Type/Mfg} �5r � + •�/� Capacity No. Compartments , PKG. TREATMENT PLT ❑ i 'Method of Disposal. Distance to ne t� ell Foundation Plroperty Line LEACHING LINE No. & Length of lines 1 40 Total length/size X Z� FILTER BED ❑ 'Distance to nearest:." Well foundation 'ZfJ f "Property"Line SEEPAGE PITS ❑ Depth Size Number F 4. - -SUMPS-. - V"'TDistance to nearest. Well - 3 Foundation" � Property-Lane :•-� r __ - .. DISPOSAL_ PONDS. ❑ 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 Home owner or licensed,a ent's si nature certifies the followin 9 cern that in the performance of the work for which this p T rules and regulations-of the San-Jtfaquin Local Health District ' g g; ' certify pe permit is issued, I shall not employ any person in"such-manner as to,become subject to-workman'scompensation laws of California.".Contractors 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 compensa- tion laws of California.": .. _ The applicant must call for allrequired inspection orrlpleYe drawing"on reverse side. _ .._ Signed Title — �. ' Date FOR DEPARTMENT_USE ONLY ' •Appicatian Accepted by Date Area — "I Final Inspection b Date Pit or Grout Inspection by Date r b-- Y Additional Comments: ' ❑ Sicantm al!"c res to: Environmental Health Permit/Services 1601 E Hazelton A _ -n Lodi 369-3621 i © Manteca 823-710 " ❑ Tracy -839743385 - 4 Appy - _ P O $ox 2008 S A , " INFO i BUNT REINITTED CK ; REC'EIVED'BY PERMIT FEE N0 AMQUNT DUE ' AM CASH ir. '+ EH 13-241REV.10/831 i �.?i I i i .r.....•_• .. __� ��..�, E. EH 14-26 I