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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PERMIT N0. _-- a 1601 ETelephoneN(209) 466O6781 DATE CA DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 f (Complete in Triplicate) is hereby made to the San Joaquin Local Health District for a permit to construct an install the work herein Application }kation is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1$62 for well/pump described. This app n Joa uin Local Health District. and the Rules and Regulatio o t �. Subdivision Nam Phone Job Address Address Phon O Owner's Name License No Contractor's Na b ; i ❑ ❑ DES NEW WELL TRUCTION ❑ . WELL REPLACEMENT OTHER ❑ a TYPE OF WELL/PUMP WORK: ❑ SYSTEM REPAIR LJ OP' LINE PUMP INSTALLATION DISPOSAL FLD. PR SEWER LINES PITS/SUMPS k DISTANCE TO NEAREST: SEPTIC TANK �� OTHER WELL � FOUNDATION I AGRICULTURE WELL �� PROBLEM CONSTRUCTION SPECIFICATIONS INTENDED USE TYPE OF WELL ❑Manteca Dia. of Well Excavation U Open Bottom Dia. of Well Casing industrial Tracy .� LJ Domestic/Private ❑Gravel Pack ❑ CJ Other ❑ Delta Type of Casing ❑ Public rax. IAPp ❑Eastern Specifications Irrigation 1 Depth Depth of Grout Seal --------------- ❑Cathodic Protection Type of Grout ❑Geophysical Surface Seal Installed by ❑Other State Work Done f Pump —.�— N.P. Repair Work Done G Type oSealing Material (top 50') Well Destruction ❑ Well Diameter _ Depth i Filler Materi��(N, ow 50') �. septic tank or seepage pit permitted if public sewer is EpADDITION available within 200 feet.),. YYPEf OF SEPTIC WORK: NEW INSTALLATION L} �. f Commercial Other ! Installation will serve: . Residence Lot size Number of a rooms Number of living units'v , ',Water tab)e depth 1 �' a^fiof 3 feet: No. Compartments Character of soil to a dept#i 11 Capacity 11 Type/Mf9.�f Method of Disposal K SEPTIC TAN —0 Capacity r Y ' Property Line pKG. TREATMENT*P.LT. ❑� ?Y- -Pl -y Foundation t SEWAGE SYSTEM Distance to nearest: Well DESTRUCTIONJ._ Total length/size j# No. & Length of lines LEACHING LINE U Foundation�' Property' Line �_,__�. EI LT ER BED ❑ Distance nearest: Well , FSize r Number �+ f SEEPAGE PITS �. ,h Del propertyLine f Foundation �� -- 511MP5. Dastanc,e to nearest: Wel1TQ__ DISPOSAL PONDS ' lication and that the work will be done in accordance with San aq n county �`*' ` �' in Local Health District. _ 1 hereby certif-y¢that I Rave prepared this app f I certify that in the performance of the work-for which this l. I ordinances,' state laws, and ru les as-d regulations of the San Joaqu Home owner or licensed agent's signature certifies the allowing: y performance of .the work for which permit is issued, I shall not';employ arson in such manner as to become subject to workn thnIse cperformanc tlfws e work forma. f P c' arsons subject to workman's com ensation laws of California." c Contractor's hiring or sub-contracting signature certifies the followiPg: "I certify that in e P this permit is issued, 1 shall employ P Complete drawing n � erse side. C/ lica must call r al required inspections. P Date:' ,` f The app Title: F , Signed XStk .466-6181 OR P 7MEN USE ONLY Area 6 1 - � App ' ation Accepted by /K Lodi 369-3621 Additional Comments: Date ❑ Manteca 823-7104 � � 835-6385 Pit or Grout Inspection by L Tracy `I Date Lr — Final Inspection by . Applicant - Return all copies to: Environmental Health ermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 App '' RECEIVED BY FEE BASE AMOUNT DUE DATE PERMIT NO. AMOUNT REMITTED rt INFO JA_ '; m o 10/82 500 1� EH 13-24 REV. 10/82 14-26