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APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT �� ' •�•� � 1601 E. HAZEL i ON AVE., STOCK70IV, CA JPERMIT Telephon ) 46e (2096-6781 EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) DEC Application is he+eby made to the San Jdaqujn Local Health District for a pe .hereig.descrltied.This application is permit to construct and/or install the work made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the RSles 4nd kegulationof-ih San Joaquin Local Health District. c.� SOL, Lot Size PM Jai .�— City Job Address (� Address �+aZ✓ � "e Phone Owner's Name Address zl License No. .._PhonEQ�`' ConAdd tractor- W TYPE OF WELLIPUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION C1 PUMP INSTAi LATiON F1 SYSTEM REPAIR 6L OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS � INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 7Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing S ecifications Qomestic/Private ❑ Gravel Pack El Tracy Type of Casing P i-1 Public f} Other i Ll Delta Depth of Grout Seal Type of Grout I 1 Irrigation —._Approx.�Depth i I Eastern Furface Seal Installed by � N.P. State Work Done Repair Work Done Type of Pump --IV Well Destruction ❑ Well Diameter Sealing Material (top 50'1 4 Depth Filler Material (Below 501 — N TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is t) available within 200 feet) + Commercial Other Installation will serve: Residence , a Number of,living units: Number of� be drodms` �"� ►` " � ' Character of soil to a depth of 3 feet-' 1 r ' Water table depth SEPTIC TANK 0 Type/Mfg "' "=Capacity - No. Compartments S Y Method of Disposal PKG. TREATMENT PLT. ❑ t t Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS I 1 Depth !! Size_ Number I SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 E V that the work will be done in accordance with San Joaquin county ordinances, state.laws, and I hereby certify that I have prepared this application and rules and regulations of the San Joaquin Local Health Diktrict`` s 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 shat) not employ any person in such manner as to become subject to workman's 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 compensa- tion laws of California." i f The applica t all for allrhe(q ed inspections. Complete drawing on verse side. g Signed Title: Date:IV L F, PAR SE ONLY F Date Z�- Area �S ' Application Accepted by •` t k Pit or Grout Inspection by Date Final Inspection by Date ' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 © Tracy 1-835-6385 j Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 . FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO y- * ♦ EH 13-241REV.1/R5) - � EH 14-29 1 - G .