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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH,EII �RI' t, }� 1601 E. HAZELTON AVE., STO KaQ k CA } 1�' ��i PERMIT NO. Li Telephone (209) 466- ,�> %y� 5\� DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4� (Complete in Triplicate) �,it� J � .9 Application is hereby made to the San Joaquin Local Health District for a permitVo 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. Job Address / Subdivision Name,} Owner's Name Address Phone Contractor's qme yki License No. CJ Phone 2:�9_- ' TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT DESTRUCTION E] PUMP INSTALLATION SYSTEM REPAIR OTHER Z DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial U Open Bottom E] Manteca Dia. of Well Excavation Domestic/Private F_�Gravel Pack F-1 Tracy Dia. of Well Casing Public Cj Other D Delta Type of Casing Lj Irrigation Approx. [] Eastern Specifications Cathodic Protection ❑ Depth Depth of Grout Seal ❑Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done Ej Type of Pump 9JIL, H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') t, �h Depth Filler Material (Below 50') 01t TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK E] Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal . SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ fiv LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size. Number SUMPS Distance to nearest: Well Foundation Property Line 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 rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that 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§ compensation laws of California." Contractor's 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 compensation laws of California." The applicantmust cfor all required inspections. Complete draMpg on reverse side. �7 Signed XZ/" L , �Q1_— Title: Date: V. i R DEPARTM T E ONLY 3 < Application Accepted by Area ® Stk 466-6781 v/ Additional Comments: [] Lodi 369-3621 Pit or Grout Inspection b _ Date (� � Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copi Environmental Health Permit/Services 1601 E. Hazel on Ave., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO L 10/82 500 EH 13-24 REV. 10/82 O / 14-26