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APPLICATION-FOR FtR '' ' 1 ;:.SAN JOAQUIN LOCAL,HEALTH`I}lST:RfCT; 1 .1601 E. HAZEL T ON AVE., STOCKTOI" •CA -- ar -Telephone (209) 466-6781 PER- Off EXPIRES 7 YEAR FROM DATE ISSUED 4F (COmplete in Triplicate] Application is hereby made to the San Joaquin Local Health District for a made in compliance with San Joaquin County Ordinance No. 549 for sewage or No, 7862 for t and/or i and the Rules and Regulations permit to construct andlor install the work herein described. This a Local Health District. F application is " 9 ns of the San Joaquin Job Address City Lot Size Owner's Name r PM Address �- Contractor L Phone TYPE OF WELL/PUMP: ?ddress S d r ~ NEW WELL ❑ - s License IVo. �s Phone ~~ PUMP INSTALLATION El WELL REPLACEMENT F1SYSTEM REPAIR ❑ DESTRUCTION ❑ DISTANCE TO NEAREST: SEPTIC TANK ' —�' SEWER LINES OTHER p FOUNDATION AGRICULTURE WELL DISPOSAL FLD. PROP. LINE INTENDED USE TYPE OF WELL OTHER WELL PITS/SUMPS ❑ Industrial PROBLEM AREA CONSTRUCTfON SPECIFICATIONS ❑ Open Bottom ❑ Manteca~ C] Domestic/Private Dia. of Well Excavation ❑ Gravel Pack ❑ Tracy T Dia. of Well Casing f`l Public ❑ Other Type of Casing 1 Irrigation ❑ Delta Depth of Grout Seal Specifications —.Approx. Depth I 1 Eastern Type of Grout O Repair Work Done Of Seal Installed by ❑ Type of Pump H.P. Well Destruction ❑ Well Diameter State Work Done_ - Sealing Material (top 50') Depih TYPFiller Material (Belq`w_50') E OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADD11 ITIO11 N i I DESTRUCTION i I rc system permitted if public sewer is Installation will serve: Residence �— ^"' available within 200 feet.) r — Commercial_ _ether .! Number of living units: Number of bedrooms t Character of soil to a depth of 3•feet: SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ y Capacity No. Compartments t r k i.Method of Disposal f Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No..& Length of lines FILTER BEDTotal length/size ❑ Distance to nearest: Well Foundation l Property Line SEEPAGE PITS 11 Depth Size Number SUMPS ` LI Distance to nearest: Well Foundation DISPOSAL PONDS ❑ s Property Line 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'strict...�: . ' i r I Home owner or licensed agent's signature certifies the following: "1 certify that in the'performance of the'work for which this permit is issued, I shall not oy any person in such manner as to become subject to workman's compensation laws of California.':Contractor's hiring or sub-contracting signature certi i he 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 o a'fornia.' F r� I The applica t st cal fo all r uired i s c o s late drawing a ever a si 3 Signet Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Pit or Grout Ins pection by Date Final Inspection by - 7c :� - : Date' Additional Comments: O_Stk 466-6781 ❑-Lodi 369 1,,�,-m..Mantaca_t323 7104-- .O:Tracy,-f335 6385 Applicant - Return all copies to: Environmental Health Permit/.Services 1601 E. Hazalton'Ave--r P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK r INFO CASH RECEIVED 13Y DATE PERMIT'NO. EH 13-2�[REV.tiesr �Sy rH 1428 (P t �� 'y