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a - ' APPLICATION FOR PERMIT _ � . SAN JOAQUIN,LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,-S70GK70N, CA r.. `Telephone 12091 466-6781 If . r PERMIT EXPIRESA YEAR FROM DATE ISSUED ; j (Complete in Triplicate) J�' application is f* f►' Y F No.5is for sewage or No. con for welllpump and the Rules and Regulations of the San Joaquin l Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described, s app made at L made in compliance with San Joaquin County Ordinance Local Health District. r. r "r /'�f rr�u /► e� /� - �a I, ' Lot Size PM Job Address f-'3`J ' ` b City J " r_ �. _ Phone er �� Address. Owner's Name _ License No. '�� Phon ed Address DESTRUCTION LJ WELL REPLACEMENT ❑ NEW WELL OTHER 15TYPE OF WELLlPUMP: SYSTEM REPAIR ❑ PROP. LINE r PUMP INSTALLATION =---= ' —DISPOSAL FLD. SEWER'LINES PITSISUMPS r DISTANCE TO NEAREST: SEPTIC TANK 'S -= OTHER WELL AGRICULTURE WELL _ l 1 FOUNDATION _—� -� '_FE_E F(C4 PROBLEM ARE'°' CONSTRUCTION 5PEC1FlCATIONS r- -INTENDED USE !TYPE OF WELL ` Dia. of Well Casing ❑ Open Bottom ❑ Manteca Dia.of Well Excavation ❑ Industrial 7� Specifications 1 ❑ Tracy Type of Casing_ Ty e f Grout Domestic/Private ' Gravel Pack Depth of Grout Sea ❑ Delta l ❑ Public ❑ Other ace Seal Installed by i. � pp Arox. Depth ❑ Eastern } ❑ Irrigation l H.P. State Work Done— e of Pump �C2 Lam— '' Repair Work Done ❑ Typ Sealing Material (top 50') ❑ Well Diameter `. r 'n i Well Destruction F.� 5 elow 50'1 Filler Material (B Depth is available within 200 feet./ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRlADDlT10N ❑ DESTRUCTION ❑ (No septic system permitted if public sewer I Commercial Other_— i _ Installation will serve: Residence k Number of living units: t Number of bedrooms �. , Water table depth. r a I Character of soil to a depth of'3 feet: Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg 4 Method of Disposal { PKG, TREATMENT PLT. ❑ Foundation-_1'. Property Line Distance to nearest: Well ry Total length/size LEACHING LINE ❑ No. & Length of lines Property Line FILTER BED ❑ Distance to nearest: Well -Foundation ❑ Depth Size I SEEPAGE PITS Foundation Property Line SUMPS ❑ Distance to nearest: Well DISPOSAL PONDS ❑ application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this app ., '"" rules and regulations of the San Joaquin Local Health District. .� t ' ce g: .. y become subject to workman's compensation laws of California." Contractor's hiring or subject t workman'1scompensa- Nome owner or licensed agent's signatureeC certifies the following: 1 certif that in the performance of thework fpr which this permit is issued, 1 il ignature shall not f employ any person in such manner as to b i certifies the following:"I cerfify that in the performance.of the work for which this permit is issued, I shall employ tion laws of California. p�7 applicant must call for I requir, inspections. Complete drawing on reverse side. f The app a Date: Title: k Signed . FOR 'DEPARTMENT USE ONLY Area Date !�, Application Accepted by C ate �J 1 t ate ��Final Inspection by � Pit or rou Inspection by r Additional Comments: ❑ Manteca 823-7104 - 0 Tracy 835-6385 0 Stk 466-6781 L3 Lodi 369-3621 Stk., CA 96201 E Applicant - Return all copies to: Environmental Health PermitlServices 1601 E. Hazelton Ave., P.O. Box 2009, It CK RECEIVED BY DATE PERMIT'NO. FEE AMOUNT DUE AMOUNT REMITTEDC SH 7` INFO + EH 13-24(REV.I/FI!,I EH 14.26