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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STgCKTgiV, CA Telephone (209) 466-6781 � PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDFly (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 M made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/purnp and the Rules and Regulations of the San Joaquin } Local Health District. l of l /"!�. t%zw 4 PM Job Address CityLot Siz Owner's Name Address ��1� _ -_ Phone �� _�. Contractor Address - �License No. Phone I ' Fj TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS E INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open 66ttom ❑ Manteca Dia" of Well Excavation Dia. of Well Casing i [_1 Domestic/Private ❑ Gravel Pack Jtfracy Type of Casing Specifications E (1 Public ❑ OtF�er F1 Delta Depth of Grout Seal Type of'Grout t I Irrigation 1_Approx. Depth I I Eastern Surface Seal Installed by I. Repair Work Done ❑ Type of Pump H.P. State WorV Don _ Well Destruction ❑ Well Diameter Sealing Material (top 5011 a0 ' Depths Filler Material (Below 501 TYPE OF.SEPTIC WORK: NEW INSTALLATION'l'1 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is ry t available within 200 feet.) nvJJj Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth 3 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments `k PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest:' Well -Foundation Property.Line l� LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 7 r+J I` SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Di?trict. k 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 r employ any person in such manner as to become subject to workman's 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 compensa- tion laws of California." The applicant usticall a d ctions. Complete drawing on reverse side. Signed X < L` C� Title: �I .'� Date: it s FOR DEPARTMENT USE ONLY Application Accepted by Date Are Pit or Grout Inspection by Date Final Ins ction by Date Additional Comments:' # ❑ Stk 456-6781 ❑ Lodi 369-3621 ❑ Man ca 823-7104 ❑ Tracy 835-6385 l� Applicant - Return all copies to: Environmental Health.Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK fFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. t EH 1324{REV,t i x 51 EH t4-26 �i "