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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 5 1601 E. HAZELTON AVE., STQCKTON, CA Telephone (209) 466-6781 O PERMIT EXPIRES T 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 for sewage or No.1862 for welllPump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.54 Local Health District. .(A r City Lot Size /T � 11. �� PM Job Address -7-7 -21 57 Address Phone N, t Owner's Name qq �+ Contractor Address License NoIJJ� '7/ Phone O 1J TYPE OF WELL/PUMP`. NEW WELL ❑. "_ WELL REPLACEMENT ❑ DESTRUCTION ❑ _ PUMP INSTALLATION ❑ 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 J ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation pia. of Well Casing + b bomestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications f.'1 Public. L7 Other f--1 Delta Depth of Grout Seal Type of Grout-- . I I I Irrigation —Approx. Depth I l Eastern Suriace Seal Installed by 1 Repair Work Done El Type of Pump H.P. State Work Done' Well Destruction Li Welt Diameter Sealing Material itop 50') _ 1 Depth Filler Material (below 501 } TYPE OF SEPTIC WORK: NEW INSTALLATION IV REPAIR/ADDITION I.t DESTRUCTION I 1 IINo able syit m rmit)ed if public sewer is Installation will serve: esidence ! Commercial Other Number of living units: Number of bedrooms t of soil to a depth of 3 feet: Water table depth Character, SEPTIC TANK ❑ Type/Mfg �� — Capacity f r� a No. Compartments PKG. TREATMENT Pt .❑ �— / Method of Disposal " Distance to nearest: Well 1.� oundation 6/ Property Line r+ q j LEACHING LINE ❑ No. & length of lines '� Total length/size FILTER BED ❑ Distance to nearest: Well/d � foun ation/1�l Property Lin � SEEPAGE PITS p l ! Depth $IZe Number — r SUMPS Ll Distance to nearest: Well foundation� _ Property Lin i DISPOSAL PONDS Ii ❑ I hereby certify that I Aaye prepared this application and that a 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 parson in such manner as to become subject to workman's compensation laws of California."Contractor's hiring of sub contracting signature certifies the following:i'I certify that in the performance of the work for which this permit is issued,I shell employ persons subject to workman's compensa- tion laws of CalitOrnla rt' The applicant Tst call fora a d ipeLe si airetlons. Compl a drawing reversde. Date, Signed Title: d FOR DEPARTMENT USE ONLY _ Application Accepted pate LI Area � w Grout inspection by Final Inspection by te -- — r (/Additional Comments: 0 Sik 46&6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant • Return all 'opies to: Environmental Health PerrnitlSelvices,1601 E. Hatelton Ave., P.O. Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED 9Y DATE PERMIT'NO. 5 INFO l !' I a Eft 13.24IREy.I nal EH 14-28 L/O . i