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APPLICATION FOR PERM] �j € t Ell SA.N JUAQLi,"; LOCAL HEALTH D:STRfCT 1601 E. hAZELTON AVE., T JAIL - s o ,.�. s S6-6781ii" CA °� PERMIT N0. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE- ISSUED � •�� .��f�? UIN. L[�'j�,,'P�LE ISSUED 1 S g I (Complete in Triplicate} HEALTH USTRICT described, Thislication- is ereby applicationoishmadeninocomplia�celwithlSanOJoaquin County Ordinance No. 549 f and the.Rules and Regulations of the San J_oaauin Local Health 0istnict, permit to construct and/or install the work herein or sewage or No. 1862 for well/pump I Job Address �.? � � Owner's Name a� Subdivision NameSG_�,�r,.� F Contractor's Name' Address, `q�. S r7 f License No. 2° Phone —2 TYPE OF WELL/PUMP WORK: '.. - Phone ZQ NEW WELL ❑ WELL REPLACEMENT PUMP INSTALLATION ❑ DESTRUCTION �.�_.` SEWER LINES DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ DISPOSAL FLU.OTHER ❑ FOUNDATION AGRICULTURE WELL PROP, LINE OTHER WELL PITS/SUMPS INTENDED USE --- TYPE pE WELL PROBLEM AREA Industrial --.--_ CONSTRUCTION SPECIFICATIONS LJ Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private ❑ Gravel PackTracy ❑ Public ❑Other Delta Dia, of Well Casing ❑ ❑ � Irrigation A Type of Casing L] Cathodic Protection Depth ❑ Eastern P Specifications I'�{ ❑Geophysical Oepth of Grout Seal UJ Other Type of Grout �t Repair Work DoneSurface Seal Installed by Well' Destruction Well Diameter i Type H.P. State Work Done �. ❑� Pump - _.� Sealing Material (top 50') Depth Filler Material (Below 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION JJ (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence _ Commercial within 200 feet.) Commercial available ` Number ofliving units: Number of bedrooms ! Character of soil to a depth of 3 feet: Lat size R SEPTIC TANK CJ Type/Mfg Water table depth PKG. TREATMENT PLT. Capacity No. Compartments ❑ Type/Mfg Capacity p' + SEWAGE SYSTEM Distance to nearest: Well Method of Disposal DESTRUCTION ❑ Foundation Property Line LEACHING LINE ❑ No. & Length of lines FILTER BED Total length/size ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 0 Depth Size SUMPS Number LI Distance to nearest: well Foundation DISPOSAL PONDS, ❑ Property Line 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 compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I sh 1 employ persons subject to workman's compensation laws of California." i The appli t mus call f all uired inspections. Complete draw' on reverse side. Signed X q Title: � Date: FOR DEPARTMENT USE ONLY Application Accepted byt —5-8 Area Additional Comments: ❑ Stk 466-6781 Pit or Grout Inspection by ❑ Lodi 369-3621 Date Manteca 823-7104 Final Inspection by � Date Zd ❑ Tracy 835-6385 Applicant - Return all copies Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE. AMOUNT DUE AMOUNT REMITTED INFO RECEIVED BY DATE PERMIT N0. EH 13-24 REV. I0/82 14-26 10/82 500 �e q