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APPLICATION FOR PERMIT ICT SAN JOAQUIN LOCAVHEALTH OCKTON RCA r HAZEL IA 1601 E. ON 6781 F Telephone (209146' DATE ISSUED t PERMIT EXPIRES 1 YEAR FROM application is (Comp Tete in Triplicate)- i i in Local Health District for a p and tris Rules.and Regulations of the San Joaquin permit to construct andIor install the work herein described. sap r Ocation is hereby made to the San Jcaqu Ordinance No.549 for sewage or No. 1862 for well/pump APP r made in compliance with San Joaquin Coi my �� PM Local Health District. 1 * Lot Siz ! I City Phone Job Address + ° Address I Phony Owner's Name License �� l�lo. Z ! fAddress DESTRUCTION ❑ > ! r WELL REPLACEMENT ❑ OTHER D i Cl I -W WELL ❑ f TYPE OF WELLIPUMP: r, SYSTEM REPAIR ❑ PROP. LINE . PUMP INSTALLATION ❑ T -� DISPOSAL FLD•�-- PITS/SUMPS TA SEWER LINES __� .F OTHER WELL�—�- Y DISTANCE TO NEA SEPTIC TANK AGRICULTURE WELL �- 1 FOUNDATION PROBLEM AREA., CONSTRUCTION SPECIFICATIONS Qi o Well Casing ; I TYPEOF WELL__.. � INTENDED-USE..-__- - - ❑ Manteca Dia- of Well Excavation Specifications C3 industrial d open Bottom Type of Casing Type of Grout ❑ Gravel Pack D Tracy Seal ❑ Domestic/Private C1l I Eastern Delta Depth of Grout k F1 Other y 1 I'1 Public Surface Seal lnstallad by r _-Approx. Depth s State Work Done I I Irrigation H.P. T�, Repair Work Done ❑ Type of Pump _Sealing'-Material )top 501 Well Destruction ❑ Well Diameter -� -. 4 ler Material (Below 50'1 is Depth - available within 200 feet.) SEPTIC WORK: NEW INSTALLATION l 1 REPAIR1111, DDlT,ION- DESTRUCTION_) 1 -IN system permitted if public sewer TYPE OF SEP f; installation will serve:. Residence Commercial Other r Number of be oms ter% „��: Water table depth Number of living units: "1 Ass Character Of soil to a depth of 3 feet: u*` Capacity—� No. Compartments SEPTIC TANK -1TypelMfg' - � Method of Disposal� l PKG. TREATMENT PLT.El . . l Property,Line -AlFoundation��--- l �= Distance to nearest: Well �-- � Total fengthlsize LEACHING LINE .❑ No. & Length of lines. -- Foundation�--- Property Line FILTER BED ❑ Distance to nearest: Well i umber Depth Size !Y��.— 3 Property Line SEEPAGE PITS X /�(� Foundation�1[� CI Distance to nearest: Well t'r .._x l SUMPS ' inances:,state laws, and DISPOSAL PONDS ❑ hereby certify that l have prepacounty ofd red this application and that the work will be done in accordance with S w�k fo which this pe m f is issued I shah not rules and regulations of the San"Joaquin Local Health Di§trict. l certify that in.the performance of the Home owner or licensed agent's signature certifies the following: ' rs's h subject to workman's compensa G employ any person in such manner as to become subject to workman's he work for co chthss perm tvis issued,fI shall employ Contractor's s hiring csub-contracting signature certifies the following: "I certify that in the per tion laws of California." 1, The applicant must if for Are ed inspections. Complete drawing on reverse idDate�� r Title: ' 1 Signed FOR DEPARTMENT USE ONLY ' ; / Area 2Z A Date Application Accepted by �. Dal Date Final Inspection by or Grout inspection by 6 Additional Comments: Ll Manteca 823 7104 ❑Tracy 835-6385 5201 ❑ Stk 466-6781 ❑ Lodi 369-3621 ' Applicant - Return all copies{o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 9 1 CK RECEIVED BY DATE PERMIT'NO. )NFO AMOUNT DUE AMOUNT REMITTED CASH l *.EH 13-24(REV.'/All EH IC2a