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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PERMIT N0. 1603 ETelephoneN (209),466-67801N, CA Y DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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._ 1862 for well/pump and the Rules and Regulations f the SAn Joaqui notal ealth ar District. Job Address Subdivision Name Phone Owner's Name A dress Phone Contractor's Name License No. f" TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT R DESTRUCTION [] PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . DISPOSAL FLD. PROP. LINE _ T FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS CONSTRUCTIONPECIFICATIONS S INTENDED USE TYPE OF WELL PROBLEM AREA _.�--- Industrial [Open Bottom ❑Manteca Dia. of Well Excavation Domestic/Private Gravel Pack [Tracy Dia. of Well Casing Public Fl Other [] Delta Type of Casing LIrrigation Approx. Specifications ecifications"� i .1 ❑,._Eas_ er Cathodic Protection Depth Depth of Grout Seal G Geophysical Type of Grout Other Surface Seal Installed by ` H P. State.Work Done i Repair Work Done Type of Pump Well Destruction U We11NDiameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW'INSTALLATION LJ` REPAIR/ADDITION �(No septic tank or seepage pit permitted if public sewer is tiavailable within 200 feet.) Installation will serve: Residence / Commercials_ Other Number of living units: �� Number of bedrooms Lot size I Water table depth 1 4 Character of soil to a depth of 3 feet: ► i /-,v 1 Capacity No. Compartments- SEPTIC TANK LNFIV Type/MfgMethod of Disposal PKG. TREATMENT PLT. 17Type/Mfg ` Capacity - i Septic Tank Distance to nearest:- Well Foundation Property Line Destruction A : LEACHING LINE - No. & Length of lines Total 1 ength/size ' F-1 Distance to nearest: Well Foundation Property Line FILTER BED SEEPAGE PITS Depth .� � 5ize Number �r L-ine1� " SUMPS U Distance to nearest: Well_� oundation Property d.} .+ r DISPOSAL PONDS 4 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. i 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 t compensation laws of California." iii 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 applica s call /r all requi.e inspections. Complete drawing on reverse side. Date Signed X h! Title: r}. - FGRPAR MENT U ONLY - .Area /-+- •--- Stk -,466-6781 Application Accepted by Lodi 369-3621 Additional Comments: P% �4 f �' �""'l� w j A- i ? � Manteca :S 3-7.104 Date , f Pit or Grout Inspection by �7f'``" pate : }�4Tracy .35-6385 �s Final Inspection by t Applicant Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave.`T P.O . Box 2009, Stk., GA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE q PERMIT] NO. INFO � � 0 U 10/82 500 f EH 13-24 REV. 10/82 14-26 i