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APPLICATION FOR PERM- -SAN JOAQbif; LOCAL "EA.LT:F 31STRICT 1601 E. HA?ELTpN AVE., ST nC KTON, CA PERMIT N0. - Telephone (209) 466-6731 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 An Joaquin Local Health District, Job Address Subdivision Name Owner's Name ddress �-/G Phone a;?Contractor's Name License No. .09,2x/ Phone 36F:�7; 3 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �-�J _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE l 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 ❑Other ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth _Depth of Grout Seal ❑Geophysical Type of Grout 71 Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction E] Well Diameter Sealing Material (top 50'). Depth Filler Material (Below 501) 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 _Aa� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg On ,A �dy Capacity /.256 No. Compartments PKG. TREATMENT PLL ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM � Distance to nearest: Well Foundation &O• Property Line DESTRUCTION J;S r LEACHING LINE (`.+', No. & Length of line _ k Total length/size FILTER BED ❑ Distance to nearest: Well Foundation _ Property Line j �p U SEEPAGE PITS Depth pZ S� Size 3_ Number ( . SUMPS ❑ Distance to nearest: Well l!o , Foundation Property Line DISPOSAL PONOS ❑ 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 workmans 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 shallempI persons subject to workman's compensation laws of California." The applican s c for re ired inspections. Complete drawing on reverse side. `L p Signed X Title: Ll/1�• Date: !O P FOB_ PARTMENT US ONLY Application Accepted by ( ,p�� g� Area 0l ❑ Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by . Date ! ❑�Manteca 823-7104 Final Inspection by ' z iF,� ! LD//S/f6�7 Date � f �'� -i ❑ Tracy 835-6385 Applicant - Return all copies 1 : _Environmental Healt Permit/Services 1fi01 E da zeltpn Ave., P.O. Bax 2009, Stk., CA 95201 FEE I BASE AMOUNT 1UEj AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO i '_0/R2 500 EH 13-24 REV. 10/82 14-26