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APPLICATION FOR PERMIT SAN JOAQI,IN LOCAL HEALTH DISTRICT 1601 E. lephcnDN AVE., STOCKT66-678ON, CA PERMIT NO. S . Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED f� 2 (Complete in Triplicate) 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. 1662 for well/pump and the RulekNa ula ions otthSan Joa uin Loc e lth District. Job Address-404 4 Subdivision Name .+ Owner's Name Address Phone Contractor's ' LicenseNo. Phone -S'", os- TYPE OF WELL/PUMP WORK: ..NEV; WELL WELL REPLACEMENT DESTRUCTION U �V PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE STYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I 1 Industrial U Open Bottom D Manteca Dia. of Well Excavation U Domestic/Private ❑ Gravel Pack ❑ Tracy Dia, of Well Casing Public Other Delta Lj Irrigation Type of Casing Approx. Eastern E] Cathodic Protection Depth Specifications Geophysical * "� Depth of Grout Seal U Other Type of Grout Surface Seal Installed by Repair Work Done [] Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 501) y TYPE OF SEPTIC WORK; NEW INSTALLATION L EPAIR ,ADDITION [A�No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence available within 200 feet.) ' - _ Commercial Other Number of living units: _._.,L— Number of bedrooms _ Lot sya.e Character of soil to a depth of 3 feet: .�'` Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ii 77 Distance to nearest: Well Foundation Property Line Cl DESTRUCTION LEACHING LINE � No. & Length of lines Q Total length/size �'' FILTER BED Distance to nearest; Well r Foundation /� Property Li �- 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 workman'§ 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 applicarfmust call r 1 required inspections. Complete drawing on reve a sidg. Signed X Title: , ! �/ �� Date: OR E RTMEN7 USE ONL Appl ation Accepted by Area ❑ Stk' 466-6781 Additional Comments- Lodi 369-3621 Pit or Grout Inspection by Date � Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies o: Environmental Hea Vh Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO D- �3 EH 13-24 REV. 10/82 10/82 500 14-26