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APPLICATION FOR PERMIT df��rcQ SAN J0AQUIN LOCAL HEALTH DISTRICT 77 p 1601 ET0N eileptw (209)� CA 466-6781 PERMIT N0. PERMIT x? E lilES 1 YEAR FROM DATE ISSUEDrus(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 w 1 and the Rules and PA 1-H s cf.AAWSAn .lnaouin Local health District. Joh Address ' ", /y ; Subdivision Name r larki;, Owner's Name r. Addressa� i Phone Contractor's Name k License No. Pnane TYPE OF WELL/PUMP WORK:�"i NIb! WELL i ❑ WELL REPLACEMENT ❑ DESTRUCTION❑ i' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ '� DISTANCE TO NEAREST: SEPTIC TANK SEWEq LINES DISPOSAL FLD. PROP. LINE „ FOUNDATION AGRICULTURE WILL OTHER WELL PITS/SUMPS " INTENDED USE ! TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,I J ]ndustrial i ❑Open Bottom ❑Panteca Dia, of Well Excavation � LI Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public [[i Other [] Delta ' irrigation �, Type of Casing l._V g Approx. ❑ Eastern ❑Cathodic Protection ' Depth Specifications 1 iI Depth of Grout Seal I ❑Geophysical li Type of Grout ,. ❑Other �! , Surface Seal Installed by Repair Work Done❑ Type of Pump H.?. State Work Done NtWell Destruction ❑ .,Well Diameter Sealing Material (top 501) ' „ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIAMITION ❑ (No septic tank or seepage pit permitted if public sewer is 1 I available within 200 feet.) Installation will serve: Residence Commercial _ Other y Number of living units: _-/___ Number of bedrown f Lot size Character of soil to a depth of 3 feet: 14Y Water Cable depth 3 SEPTIC TANKF[�11 Type/Mfg _(y1►l G r e t P Capacity 0 0 No. Compartments l w p- _ PKG. TREATMENT PLT. .E Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation js a' Property Line 3 ' DESTRUCTION C]'` -- LEACHING LINE No. 8 Length of lines _I + &Q Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line �• SEEPAGE PITS �i Depth 15 ' Size Number / y ' SUMPS ❑ Distance to nearest: Well Foundation I 'Praperty Line DISPOSAL PONDS ❑ . �I. �$ GPW�♦ �rl �fi'z s�l ® r^P !� L�L'G�dT`al' � .. n I hereby certify that I'have prepared this appi ication 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,": n 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 applican ust alhf"for all required inspections. Complete drawing on reverse side. 1 Signed X Title: Date: F(h DEPARTPOff USE ONLY Application Accepted by Area &3 ER-`Stk 466-6781 Additional Comments: T ❑ Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 3 Final Inspectionriby Date / L7 Tracy 835-6385 Applicant - Return all �kopi Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk•, CA 95201 I` 1 I#s FEE BASE 11 AMOUNT DUE AMOUNT REMITTED RECEIVED SY DATE PERMIT NO, :f S INFO i s �i EH 13-24 REV. 10/82]l PJ n r.S� 13/92 500 14-25 L�I �! I