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APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.-H_ AZEL T ON-AVE., STOCKT_ ON, CA Telephone (209) 466-:6781- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED,. . .�(Complete.in Triplicate) tr,; ._rc Application is hereby made to the San Joaquin Local Health District for a permit 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 Address _ �� ti1'1 � �'�G` —City Lot-Size `7 PM Owner's Name ` : Address - :2,a1 J �- -- C.�.L Phone Contractor's Name -. License Na. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El 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 ❑ Industrial ❑ Open Bottom ❑ Manteca4 Dia_. of Well Excavation Dia. of Well Casing ❑ Domestic/Private El Gravel Pack 13Trac Tpe of Casing `�— � Specifications I Y.,Ty _ 9 ❑ Public ❑;Other ❑ Delta Depth of Grout Sea! ± Type of Grout ,} q ❑ Irrigation -L—Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. .t State Work Done j '. Well Destruction ❑ Well Diameter Sealing Material (top 501 t 1 I. Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑%:REPAIR/ADDITION`❑,6 DESTRUCTION ❑ (No.septic system permitted if public sewer is aKailbbld;within•200 feet.) I g Lj Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms } Character of soil to a depth of 3 feet: c Water table depth SEPTIC TANK 13Type/Mfg l Capacity -` No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal Distance to nearest: Well. f Foundation Property Line LEACHING LINE BNo. & Length of lines f �� Total length/size Q �0 FILTER BED ❑ 1DIstar%LWaRaZ: wWell Foundation'-' •'Property Line I SEEPAGE PITS 1-1Depth �__ _Sio umber } SUMPS ❑ Distance to nearest:: Well"—�-- Foundation Property Line id/• J DISPOSAL PONDS F7 i 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 tow, man,'s.compensation-laws,of�-California.''-Contractors 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." l The applicant t call for required ins ctions. Complete drawing on_rev�erse side.., ^• Signed -�- �// J Date: •S' FOR DEPARTMENT USE ONLY 0 Z Application Accepted by Date Area f Pit or Grout Inspection by Date Final Inspection by Date z Additional Comments: /Kptk -4664781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE' AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO.' INFO CASH +EH 13-24 MEV.10/831 EH 14-28 - -