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APPLICATION FOR PER ;T LOCALSAN JDAQLill: 1601 E. AVE.,HEALTH FIL �" CO PERJIT NO, U 3' r Telephone (209) 466--6781 r,. r ' DATE ISSUED � j �f Nj 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 229 7 LXa,�l—,cof— Subdivision Name Owner's Name C164 Address Phone Contractor's Name icense No. 2 2 Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE S` I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial U Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑Other ❑Delta Type of Casing Irrigation Approx. ❑Eastern Specifications Depth Cathodic Protection ❑ Depth of Grout Seal � ❑Geophysical IType of Grout LJ Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION available within 200 feet.}REPAIR/A ITION }J (No septic tank or seepage pit permitted if public sewer is Installation will serve: Reside ce �" Commercial _ Other 9 m Number of living units: --/-- Number of bedrooms „3- Lot size do �-- Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ❑ Distance to nearest: Well Foundation Property Line DESTRUCTION LEAGHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PIES DepthSize Number . SUMPS Distance to nearest: Well Foundation O Property Line DISPOSAL PONDS C1 I hereby certify that 1 have prepared this application and.that the work wil1 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 fallowing: "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 workmanIs 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 shall employ persons subject to workman's compensation laws of California." The applict must call r 1 required inspections. Complete drawing npverse side. / Signed X r Title: Date: J FOR DEPARTMENT USE ONLY App ation Accepted by Area ❑ Stk 466-6781 Additional ftmments: Lodi 369-3621 Pit or Grout InspectiAb DateManteca 823-1104 Final Inspection by Date � ❑ Tracy 835-6385 Applicant - Return all copienviro mental Health PI Services 1601 E. azelton Ave., P.O: Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 10/82 500 EH 13-24 REV. 10/82 14-26 t