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E1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH.FDISTRICT 1601 E. HAZEL T ON AVE., 5TOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 9 YEAR FROM DATE ISSUED - (Complete in Triplicate/: Application is hereby made to the San Joaquin Local Health District for a permit to construI ct and/or install the work herein described. This application is egulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and R Local Health District. �� of Size PM City � Job Address t"— t4 At' ddress 4 r — Phone Qwner's Name i i rf Contractor i Address License No. Phare TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT,?d DESTRUCTION ❑ SYSTEM REPAIR ❑ OTHER ❑ # PUMP INSTALLATION ❑ f SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST:.SEPTIC TANK _ , FOUNDATION AGRICULTURE WELL - OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia, of Well Casing ❑ Open Bottom ❑ Manteca Dia. of Well Excalation El Industrial IE Specifications 4 ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing 1�► Type of Grout Ci Delta Depth of Grout Seal F] Public f 1 Other ;t _ I l Irrigation _.-Approx�.Depth t I Eastern Surface Seal Installed by H p State Work Done Repair Work Done 0 Type of Pump r Well Destruction ❑ Well Diameter Sealing Material (top 501 " r Depth ° Filler Material (Below 50' 4 Oce TYPE OF SEPTIC WORK: NEW INSTALLATION 6-l. REPAIR/ADDITION l I REST I No septic system permitted if public sewer is �] " t available within 200 feet.) I Installation will serve: Residence Commercial Other (e ! Number of living units: Number of bedrooms I� Water table depth Character of soil to a depth of 3 feet: No. Compartment SEPTIC TANK ❑ Type/Mfg rCapaciiy�. Malt PKG. TREATMENT PLT. Method of Dispos ❑ i Distance to nearest: Well ► Foundation Property Line {i Total length/size LEACHING LINE ❑ No. & Length of lines 1� FILTER BED El Distance'to nearest: Well Foundation Property Line i SEEPAGE PITS I Depth Size Number V Ll Distance to nearest: Well Foundation °' SUMPS • Property Line - , DISPOSAL PONDS ❑ 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 l 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 ring or sub-contractin employ any person in such manner as to become subject to workman's compensation laws signature of California." ploy Contractor's rsubject to workman's compensa- i certifies the following:"I certify that in the performance of the work for which this permit i5 issued,i shall employ p 1 f tion laws of California." The applicant must call for all required inspect- ns. Complete drawing on reverse side// Signed X Title: Date: "Z FOR DEPARTMENT USE,ONLY � (/J 1��,1� Area Application Accepted by --- —* — Date .- i .I Date Pit or Grout Inspection by date Final inspection by r it ( Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 FEE CK `RECEIVED BY DATE PERMIT'NO. INFO AMOUNT DUE-. AMOUNT REMITTED CASH +.EH13-24(REV.E/H5) )J `vV EH 14-2a h