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}' APPLICATION FOR PERMIT CAL HEALTH DISTRICT SAN JOAaUIN LO 1601 E. HAZEL?ON 2 Telephone { 091 466-6781TON A PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t (Complete in Triplicate) application s and the Rules and Regulations of the San Joaquin to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This Application is hereby made Ordinance No.549 for sewage or No. 1862 for welllpump made in compliance with San Joaquin County 9 Local Health District. ri Lot Size PM,J �.� +j City Job Address .�, a Phone- to Address, a Owner's Name 4 ,� Phone_ t � License No. � s Address DESTRUCTION ❑ Contractor O� WELL REPLACEM NT ❑ NEW WELL ❑ OTHER ❑ i� TYPE OF WELL/PUMP:. ...,. SYSTEM REPAIR ❑ PROP. LINE PUMP INSTALLATION 13SEWERLINES �� DISPOSAL FLD.— PITS/SUMPS �— DISTANCE TO NEAREST: SEPTIC TANK --- AGRICULTURE WELL —— OTHER WELL� FOUNDATION �— TYPE OF WELL PROBLEM AREA INTENDED USE CONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ Manteca D;a. of Well Excavation Specifications ❑ Open Bottom " E3 industrial "-� "" ❑`Tracy�Type of Casing ...,� Type of Grout ---- [] Gravel Pack + ° D Domestic/Private ❑ Other ! ❑ Delta Depth of Grout Sealt I- F _ aL , �. . f1 public Approx Depth• %.[ 1 Eastergn �'; Su"ace"Seal`Installed t1y �. _ Q,��•-t-�.,.�,--.�.-0....State Work"Done""_"" I I Irrigation t F.... ^. " ",t�I - Repair Work Done LJType of Primp Sealing Material (top 501 Well destruction ❑ Well Diameter !—� Filler Material iBelow 501 Depth tic system permitted i1 public sewer is k DESTRUCTION { 1 available within 200 feet.] -, TYPE OF SEPTIC WORK: NEW INSTALLATION I:! REPAIRlADDYTION lCommercial Other —�- installation will serve: Residence Number.of bedroo Water table depth f Number of living units: � 12 Character of soil to a depth of 3 feet: ° r �� Gti No. Compartments Capacity—L2 ❑ Type/Mfg g.� Method of Disposal SEPTIC TANK f p d ` PKG. TREATMENT PLT.❑ O Foundation_�—� Property Line l Distance to nearest: Well 1 Total lengthlsize LEACHING LINE ❑ No. & Length of lines a Property Line Foundation f(t undation—�— FILTER BED ❑ Distance to nearest: well f A * ,, Number SEEPAGE PITS 1 1�! C �Depth � }r i'` a"" ' Size - E_ t y iProperty Line I Foundation SUMPS P-A Li Distance to nearest: well _ sµ Y �_ ..._..• � N ,.. DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work'w;ll be dare in accordance with San Joaquin county ordinances, state laws, an� rules and regulations of the San Joaquin Local Health District. ` g: ., workman compensation laws of California." Contractor's hiring or Io workman1scompensa Nome owner or licensed agent's signature certifies the Distri in I certify that;n the performance of the work for which this permit is issued, I signature shall no employ any person in such manner as to become subject to persons subject certifies the following:'"I certify that in the performance of the work for which this permit is issued,t shall employ py tion laws of California." a The applicant ust cat]f r all requireins ctions. Complete drawing on�reverse side. Date: .2— r Title: Signed A DEPARTMENT USE ONLY t t Area Dae J � Dater 0 Applicaatiir on Accepted by Date_—r— Final Inspection by 1 Pit or Grout Inspection by S 200 r Additional Comments: , ❑ Manteca 3.7 04 ❑ T acy 835-6385 Cl Stk 466-6781 ❑ Lodi 369-9621 StlI CA 95201 Applicant . Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2(109, + CK RECEIVED By DATE PERMIT•NO. FEE AMOUNT DUI: AMOUNT REMITTED A INFO v; EH 1324 1REV. EH 14-26 !! .