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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1501 E. HAZELTON AVE., STK( TON, CA PERMIT NO. Telephone (209) 46676781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is 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. Job Address Subdivision Name Owner's Name Address Phone Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ w SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 ❑ Domestic/Private Gravel Pack ❑ Tracy Dia, of Well Casing ❑ Public ❑I Other ❑ Delta Type of Casing u Irrigation Approx. ❑ Eastern Specifications Cathodic Protection Depth EliDepth of Grout Seal Geophysical •, Type of Grout ❑Other Surface Seal Installed by Repair Work Dohe ❑ Type-ofi Pump H.P. State Work Dane Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Lot size Character jof4soi).,to a depth of 3 feet: Water table depth Capacity SEPTIC TANK �• � Type/Mfg �! P Y No. Compartments PKG. TREATMENT PLT. [] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: lti Foundation Property Line DESTRUCTION ❑ " " LEACHING LINE ❑ No. & Length of lines 11 +' Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS C DepthSize Number SUMPS ❑� Distance to nearer : '4lell- - 4oundationProperty Line c i y DISPOSAL PONDS ❑ ' I hereby certify that I have prepared this application and that the work will he 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-JJ-sued, I shall not emp4oy any person in such manner as to become subject to workmans compensation laws of California." Contractor's hiring r:'sub-contr*8tting signature certifies the following: "I certify that in the performance op the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Q StK 465-6781 Application Accepted by Area Additional Comments: Q. Lodi 3Ct9-3621 x Pit or Grout Inspectiors b Date ❑ Manteca 823-7104 Final Inspection by Date L Tracy 835-6385 Applicant - Return all co s to: Environmertal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009; 5t k., CA 95201 FFEEBASE AMOUNT DUEAMOUNT REMITTED RECEIVED BY DATE PERMIT NO. O 10/82 500 EH 13-24 REV. 10/82 14-26