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APPLICATION FOR PE2.';T SAN JOAQUIN LOCAL r.EALTH �51 1�T` 1501 E. HAZELTON AVE., STOCi<,, , �� PERMIT NO. Q LA 3�3 Telephone (209) 466-5 i !•�� 1' DATE ISSUED PERMIT EXPIRES 1 YEAR FROM C,AT ISSUED (Complete in Triplicate) Application 1s hereby made to the San Joaquin Local Health District for a peni'iiA+ig e°instruct 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 He lth District. Job Address division Name Owner's Name Address3j ClC1 Phone Lai _ Contractor's Name ` License No. �f T Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER )�. 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 I Industrial U Open Bottom Manteca Dia, of Well Excavation Domestic/Private Gravel Pack [—I Tracy Dia. of Well Casing Public f_� Other Delta Type of Casing LjIrrigation Approx. Eastern Depth Specifications ❑ Cathodic Protection Q 1 Depth of Grout Seal Geophysical Type of Grout Other �f Surface Seal Installed by �t _41� Repair Work Done ❑ Type of Pump �.�.Y� H.P. 5XI 5GState Work Done C� Cly Well Destruction U Well Diameter Sealing/Material (top 50') -4--.Ay U _ �Il Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION L.I REPAIR/ADDITION D (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 O Character of soil to a depth of 3 feet: Water table depth ` SEPTIC TANK D Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U 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 workmant 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 nust call r all required inspections. Complete drawl on reverse side. 3 Signed X Title: Date: .�/ / R DEP RTMENT E ONLY 5tk 466-6781 r� ❑ ,�/ /�ryApplication Accepted by(/� Area 3 / / Additional Comments: Lodi 369-3621 Pit or Grout Inspection Date Manteca 823-7104 Final Inspection by _ �4 CA Date L7 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Haze ton Ave., P.O. Box 2009, Stk., CA 95201 rEEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, EH 13-24 REV. 10/82 act o7 1D/$2 500 14-26