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[� APPLICATION FOR PERMiiT SAN JOAQLIP! LOCAL HEALTH 5t�� It T, ' 1601 E. HAZELTON AVE., STOGKTO?, CA PERPIIT N0. �Ai Telephone (209) 466-6 X3 Y,I LA ',1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED T• lw DATE ISSUED L (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a pernfit'-to 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 AddressjJ7dision Name Owner's Name Address Q � ,� ` Phone Q Contractor's Name License No. TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern Depth Specifications ❑ Cathodic Protection Depth of Grout Seal ❑Geophysical .�� Type of Grout ,Other "`Q''-1Surface Seal Installed by ,. 1 Repair Work Done [$ Type of Pump _ H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') `✓ Depth Filler Material (Below 50') [OQ W TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,ADDITION ❑ (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 t n Character of soil to a depth of 3 feet: Water table depth ?� d SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size Q FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number �( SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS EJ 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 workmanis 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 applicant must call for all required inspections. Complete dr . on reverse side. Signed X Title: Date: �RT ll NL Application Accepte� rea 47 ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by of g Date ❑ Manteca 823-7104 Final Inspection by 0 Date '. - ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 rIN BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. O EH 13-24 REV. 10/82 -7' 10/82 500 14-26