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APPLICATION FOR PERMIT w SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., SI OCKTON, CA Telephone (209) 466-6781 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/purnp and the Rules and Regulations of the San Joaquin Local Health District {��) C (� Job Address 14 11 _ �� C� S�� z "'Q h - City _J��'1olt Size �1 PM _ -To .S �hC� _ Address �Tyy � �.} . _� �Y_ Phone(J14 6�`I- Owner's Name _ _ _ ---- - -- - - (,—S-}- 8 oS� Contractor V\ 1C1�h _Address 2140_£ h 1�7. ----License No. __Phone b -$5ms TYPE OF WELL/PUMP: WELL ❑ WELL REPLACEMENT F] DESTRUCTION ( 1 PUMP INSTALLATION 11 SYSTEM REPAIR (1 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES __ DISPOSAL FLD. ROP. LINE \ FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �� I 1 ' Industrial ��`L///I Open Bottom ( i Manteca Dia. of Well Excavation �� -__ Dia. of Well Casing I I Domestic/Private Gravel Pack I I Tracy Type of Casing__tJZ..t_ Specifications - I 1 Public 1 Other I I Delta Depth of Grout Seal _�--_,n.__ ,Typ[e�of Grout I Irngation - Approx. Depth 1 1 Eastern SUllace Seal Installed by�t'.0 114kpL1��G �QQI Repair Work Done I I Type of Pump __I�t{-- H,P. __ —_ State Work Done Well Destruction 1 i Well Diameter -`14_ _ Sealing Material (top N%10w1AtOvo� ►ems Depth Fillet Material I Ell!lqlk TYPE OF SEPTI WORK: NEW INSTALLATION I I REPAIR/ADDITION ESTR CT (No septic system permitted it public sewer is available within 200 feet./ Installation will serve: idence _ Commercial_ Other J Number of living units: umber of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg apacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: We Foundation _ Property Line LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED 1 1 Distance to nearest: Well _ Foun ion Property Line SEEPAGE PITS I 1 Depth ----Size _ _ Number SUMPS I I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 1-1 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's 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for allmired ired ins ectio Complete drawing on reverse side. Signed X C Title- 9M 6- Date: —I OR DEPARTMENT USE ONLY Application Accepted by Date � � Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: I Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Re//turn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE J_IAMOUNT REMITTED �CASFI RECEIVED BY DATE PERMIT'NO. INFO f