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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT D LTAVE., OCKTON CA � . 1601 E. HAZE I ON AV . S Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED SEP 1988 t3 (Complete in Triplicate) IV 11 N 'f Application is hereby made to the San;Joaquin Local Health District for a permit to construct and/or install the w Pyrr .its bed. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules an56�s]}1�the San Joaquin Local Health District. 1 / llf' Lot Size PM O Job Address /t d PV[�. a/[� �l� City J!/X Owner's Name � v�e Address %W i Phone Contractor a Address License N024r7G a/ Phoney 3 TYPE OF WELL/PUMP: ,NEW WELL ❑ WELL REPLACE NT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Oia. of Well Casing 0_6`omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public n Other 1 171 Delta Depth of Grout Seal Type of Grout _ I I Irrigation _,.Approx. Depth I Eastern Surface Seal Installed by _ i Repair Work Done ❑ Type of Pump H.P. Z /`f,O�f State Work Done_ Well Destruction ❑ Well Diameter _f_._.._._ _ Sealing Material (top 501 iJ Depth_ 12 9 Filler Material (Below 50'1 j k TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION 1.1 DESTRUCTION I 1 INo septic system permitted if public sewer is QQQ fl I available within 200 feet.) Installation will serve: Residence! Commercial— Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. ❑ e , Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size r s FILTER SED ❑ Distance to nearest: Weil Foundation Property Line t t SEEPAGE PITS I I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL-PONDS Q I hereby certify that I have prepared this 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. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." i The applicant m t call for al re fired inspectio . Complete drawing on reverse side. Q Sig Title: Date: FOR DEPARTMENT USE ONLY 9,a-� Application Accepted by Date Area Pit or Grout Inspection by ate Final Inspection by Date Additional Comments: ❑ Stk 466-6781.- ❑ Lodi 365-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO - AMOUNT DUE AMOUNT REMITTED CASH ° RECEIVED BY GATE PERMIY NO. +.EH 1324 1HEV.I/A 51 5t • �� EH 14-28 �S