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GMT APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HTelepho466-6781 TON, CA ne 209) 466 6 81 t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) application is to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This ion is hereby made or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Application Joaquin County Ordinance No.549 for sewage made in compliance with San Joaq , Local Health District. ------ S�Gi Lot Size PM City c; Job Address �� •-:"-�`� �/ Phone � ,/ e� 7 Owner's Name Address} Phone_ � License No.__----- Address DESTRUCTION ElContractor WELL REPLACEMENT ElOTHER ❑ NEW WELL ❑ TYPE OF WELL/PUM SYSTEM REPAIR ❑ PROP. LINE PUMP INSTALLATION ❑ DISPOSAL FLD. SEWER LINES --- PITS/SUMPS -- DISTANCE TO NEAREST: SEPTIC TANK ------ AGRICULTURE WELL OTHER WELL_--- FOUNDATION TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing INTENDED USE ❑ Manteca Dia. of Well Excavation Specifications [I Industrial ❑ Open Bottom Te of Casing ---- ❑ Gravel Pack Elyp Tracy Type of Grout ❑ Domestic/Private Cl Delta Depth of Grout Seal _ ("1 Public Cl Other Surface Seal Installed by 1 Approx. Depth l 1 Eastern State Work Done— I I Irrigation -- H.P. Repair Work Done ❑ Type of Pump Sealing Material (top 50'1 Well Destruction ❑ Well Diameter Filler Material (Below 50') Depth tic system per if public sewer is vailable within 200 feet-I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l 1 DESTRUCTION o Sep Commercial_ Other Installation will serve: Residence _ Number of bedrooms_——— Water table depth Number of living units: J\ No. Compartments Character of soil to a depth of 3 feet: Capacity—_-- ElType/Mfg Method of Disposal SEPTIC TANK PKG. TREATMENT PLT.❑ Foundation_--- Property Line A Distance to nearest: Well----- I'\ Total length/size LEACHING LINE ❑ No. & Length of lines Foundation___-,--- Property Line_--- FILTER BED E3 Distance to nearest: Well_--- � \ _ Number J I Depth Size Property Line _-- — SEEPAGE PITS Foundation____----- SUMPS Cl Distance to nearest: Well--- DISPOSAL PONDS ❑ I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an I hereby certify thatperformance of the work for which this permit is issued, I shall not rules and regulations of the San Joaquin Local Health District. I certif that in the Home owner or licensed agent's signature certifies the following: " y arsons subject to workman's compensa- employ any perso n in such manner as to become subject to worork for;compensation which this permitVis issued,shall employ Ptor's hiring or sub-contracting signature certifies the following:"I certify that in the performance oft e w tion laws of California." . / The applicant must call for all required inspectionsCOomplete drawing on reverse side. Date: ---=— Title: Signed Xr ' FOR DEPARTMENT USE ONLY / Area Date -� Date ' Application Accepted by Date------ Final Inspection by � Pit or Grout Inspection by Additional Comments: ❑ Manteca 823-7104 ❑ Tracy 835-6385 Stk., CA 95201 ❑ Stk 466-6781 ❑ Lodi 369-3621 Applicant Return all copies 009, to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2 CK RECEIV BY DATE PERMIT-NO. FEE AMOUNT DUE AMOUNT REMITTED f 9 INFO + EH 13-24 IREV.1"'5) s- EH 14-2a