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APPLICATION FOR PERMIT SAN ,JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. WAZELi ON AVE., STOCKT01CA Telephone (209) 466 6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED i i {Complete jn Triplicatel application is /or install the work Application is hereby made to the San Joaqut . This nOrd Local alnce lth is for sewage o trict for a peIN on 1862 forcwe 1ldpump nd the Rules and herein R gulations of the Sn Joaquin P made in compliance with San Joaquin County . Local Health District. r! PM Cit , -�— r Lot Size Job Address Phone r Address 7' r .Owner's-Name- r 3(p�� fQ - S ® l License NO.. Z Z Z�' Phone r° Address i Contract % WELL REPLACEMENT ❑ DESTRUCTION ❑ y TYPE OF-WELLIPUMP: y: NEW WELL ❑ y r , � , OTHER ,rSYSTEM REPAIR I PROP. LINE i PUMP INSTALLATION ❑ DISPOSAL FLD. SEWER LINES -�---- i k ie- PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK --AGRICULTURE WELL �_ 4THEkW.ELL ---- FOUNDATION � .-- _ ' m TYPE-OF '.n.�.PROBL£MAREA-�GONSTRUGTION-SPEGIFICAT.IONS--w� pia. of Well Casing — -INTENT)ED USE Y —�� Dia. of Well Excavation 1 1 1 ❑ Open Bottom ❑ Manteca Specifications ❑ Industrial El Type of Casing 0 Domestic:/Private ❑ Gravel Pack Type of Grout {1 Other I Ll Delta Depth of Grout Seal M Public f Surface Seal Installed by I I lfrigation --Approx. Depth l 1 Eastern State Work Done Rep ,r.� e of Pump - H.P. sf ^. ° * ` t Re err WorkfDone ❑ Type Sealing Material (top 50') Well Destruction El Well Diameter Depth Filler Material (Below 50'1 f available within'200 feet..-1 TYPE OF SEPTIC WORK: NEW INS�'ALLATION I l REPAiR�ADDITION l 1 DESTRUCTION I 1 (No septic system permitted if public sewer is t installation will serve:' ResidenceCommercial,' they I�� - _�_ r _ - _ ` Number of bed oms 3 NJ;Z7, of living units: Water table depth - Character of soil to a depth of 3 feet: No. Compartments l'! Capacityl ❑ Type /Mfg TANK r Method of Disposal . PKG. TREATMENT PLT. ❑ E Foundation Property Line Distance to nearest: Well _ - -^ �,. Total length/size 4 LEACHING LINE ❑ No. & Length of lines Property Line Foundation 4, FILTER BED ❑ Distance tti�n`earest: Well r c - f Size Number SEEPAGE PITS Depth Property Line—43l not - SUMPS Ll Dista ncefto nearest: Well_-�[Q a Foundation-_ — 3 _ DISPOSAL PONDS- _ ❑ # _ _ ,_ I hereby certify that I have prepared ►his 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.g y that in work for s I Home owner or licensed agent's signature certifies the following: eompensation laws of California. Contractor's rhiringl or sub-contracting signpermit is issued, I ature employ any person in such manner as to become subject persons subject to workman's cbmpensa- _ �"l Certifies the following: '"i certify that in the performance of the work for which this permit is issued, I shall employ tion laws of California." The applicant m call for quir inspections. Complete drawing on reverse ( Date .Title:_ i Signed X t [ FOR DEPARTMENT USE ONLY i Area Date , Application Accepted by y �i DateSs� ate r l Final Inspection by ti Pit or Grout.lnspection by J Additional Comments: ❑ Manteca 823-7104 ❑ Tracy 835-6385 ❑ Stk 466-6781 ❑ Lodi 369 3621 CA 95201 Applicant- Return all copies to: Environmental Health Permit/Services 1641 E. Hazelton Ave., P.O. Box 2009, Sok:, + ` // CK RECEIVER BY.` 4ATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH f. ' INFO F ♦ EH 13-24 1 REV.1/"S 1 r EH 14-25