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- r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. 1iA-ZELTON AVE., ST C TON, CA Telephone (209) 466- a. s PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) :,: enad application is per to construct and/or install and the Rules of he San Joaquin Application is hereby made to the San Joaquin Local Health District for a p M made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for we Pum PM� Local Health District. �r 1! °' City Lot Size- F, Job Address . . Phone ` A Address Name Phon Owner's e k k "License No. � rAddress DESTRUCTION ❑ Contractor — WELL REPLACEMENT ❑ OTHER ❑ NEW WELL ❑ SYSTEM REPAIR ❑ TYPE OF WELLIPUMP: PROP. LINE PUMP INSTALLATION ❑ DISPOSAL FLD. p1TSlSUMPS �— SEWER LINES —� OTHER WELL1 DISTANCE TO NEAREST: SEPTIC TANK r� AGRICULTURE WELL FOUNDATION ' -.r TYPE OF,WELL i PROBLEM ARE CONSTRUCTION SPECIFICATIONS Dia of Well Casing \�} INTENDED USE ❑ Manteca Dia. of Well Excavation e Specifications •,.i pc ❑ industrial ❑ Open Bottom , a- Type of Casing Type of Grout (f ❑.Gravel Pack ❑ Tracy ❑ OomesticlPrivate ;� �, [I Delta Depth of Grout Seal ❑ Other Surface Seal Installed by ❑ Public �pprox. Depth r ❑ Eastern ❑ Irrigation State Work Done— ` • H.P. °..."'. 1 Repair Work Dane ❑ Type of Pump --� Sealing Material (top 50'1 I1 Well Destruction ❑ Well Diameter Filler Material (Below 501 armitted if public sewer is y Depth D TYPE OF SEPTIC WORK: NEW INSTALLATION [3REPP UP,l)DlTION ❑ ESTRUCTION L] ('Navaa septic system septic within 200 feet.? Commercial—�er -- 1 Installation will serve: Residence: A 1 Number of bedrooms-� Water table,depth Number of living units: j depth of 3 feet: ` ' T No. Compartments Character of soil to a dep i, Al C Capacity Method of Disposal i SEPTIC TANK `Jill. Type�Mfg Q PKG. TREATMENT PLT.❑ Ir Q i� Foundation_.�1� Property Line Distance to nearest: Well f01,1111if Total lengthlsize No. & Length of lines property Line l— � LEACHING LINE N �' Foundatiorr�� FILTER BED ❑ Distance to nearest: Well Fl 3 Number �i� ! •� Depth Size IL/ Property Line — SEEPAGE PITS Well��— Foundation i SUMPSstate laws, and ❑ Distance to nearest: DISPOSAL PONDS ❑ `ord . ._ orad this application and that the work will be done in accordance with San Joaquin for iwhich this permit is issued, I shall not l I hereby certify that 1 have prep I certify that in the performance of the work rules and regulations of the San Joaquin Local Health District. to arsons subject to workman's compensa Home owner or licensed a en is t gas torbecome subject follovOing: workman's compensation laws of California." Contractors hiring or sub contracting signature employ any person rformance of the work for which this permit is issued.I shall employ P certifies the following:'9 certify that in the pe tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. pate:, q Title: , Signed y �.� . OR DEPARTMENT USE ONLY O Date — `'13� Area Application Accepted by Date 1 e'. `] a`f' Final Inspect ion__ — r__ it r Grout inspection by "'1% -1 4 Y Additional Comments: ❑ Tracy 835 6385 . } EJ Stk 466-8781 ❑ Lodi 369-362 ❑ Manteca 823 7144 Stk., CA 95201 Lod ' Applicant- Return all copies to: Environmental Health Per mitlServices 1601 E. Hazelton Ave., P.O. Box 2009. PATE, PEfiMIT'NO. CK# RECEIVED f3Y FEE AMOUNT DUE AMOUNT REMITTED CASK INFO 5 r EH 13-24IREv.1/$5) O y EH 1426 s . .. .►