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F c APPLICATION FOR PERMIT d I SAN JOAQUIN LOCAL HEALTH DISTRICT a 1601 E. HAZELTON AVE 466-6781TON, CA Telephone PERMIT EXPIRES 1'YEAR FROM DATE ISSUED j (Complete in Triplicate) "described. application is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This app' made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. E1 PM/'I�P� 1 Lot Size City Job Address 1 1. - Phone r Address I owner's Name L , �Q f d _ l 7 I I N TDO r C` �ddress Ls[ense No.S��Phone_ Contractor WELL REPLA EC MENT ❑ DESYRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL THER 11 f SYSTEM REPAIR ❑ PUMP INS ALLATION �_ DISPOSAL FLD PROP. LINE i SEWER LINES plTS1SUMPS DISTANCE TO NEAREST: SEPTIC TANK � AGRICULTURE WEL OTHER WELLQd1L` FOUNDATION �I r h � INTENDED USE TYPE OF WELL � f �(U PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of We Casing ❑ Open Bottom Il Manteca Dia. of Well Excavation Cl Industrial Specifications12 ravel Pack ❑ Tracy Type of Casing �estic/Private Depth of Grout Seal . Type of Grout ❑ Other C7 Delta I'1 Public _ - ---- rn . Surface Seal Installed by t` Appro, De th i I Eastern 4� I I Irrigation ---- , H.P. State Work Done — Repair Work Done (Type of Pump Sealing Material (top 50') Well Destruction `. ❑ Well Diameter —.� — Filler Material (Below 50') Depth permitted if public sewer is vailable within 200 feet.l TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIR/ADDITION l 1 D1:STRUCTION l 1 lNo septic system Installation will serve: Residence Commercial; Other'_ Number of bedrooms 4 Number of living units: ;1 Water table depth Character of soil to a depth OIN feet: Capacity No. Compartments SEPTIC TANK ❑ Typal M - Method of Disposal 1 Ie. • PKG. TREATMENT PLT. ❑ i. Foundation !fi f Property Line Distance to nearest: ell , I .1 Total length/size LEACHING LINE Cl No. & Length Ines , undation FILTER BED Property Line ❑ Distance nearest: Well �i rSize Number SEEPAGE PITS i� th I De ! Property Line SUMPS ❑ Distance to nearest' Well Foundation DISPOSAL PONDS ❑ d I hereby certify that I have preparethis 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 following: lio ing that in the rmi Home owner or licensed agent's manne gas t re ce rtifies the me subjec�lto workman`srtcoympensation Ila soof California." Contractor's t. rhir hich ring oP sub-contracting signIt is issued, I latuore employ any person in such 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 compens I tion laws of California." I The applican t call for all required inspec'ons. Completed g on reverse side. Date: it1e: Signed X .DEPARTMENT USE ONLY W#�� Date Area Application Accepted by C� Date�L— I Date rFinal inspection by Pit or Grout Inspection by/ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 .❑ Manteca 823-7104 ❑ Tracy B35-6365 Sik., CA 95201 f vironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, „ .,,Applicant Return all capias to: En -- ' RECEIVED 9Y DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED C SH � � INFO t EH 13-24(REV.t/n 51 EH 14-26