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i APPLICATION-FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKT_ON, CA telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . (Com lete.in Triplicate) }F- JUT w p p , 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 i 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 C `� � `�—`:City �r Lot Size PM Owner's Name Address (L2 . Phone Contractor's Name No j 3 / Phone 9 TYPE OF WELL/PUMP: i NEW WELL � WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATIONSYSTEM REPAIR C1OTHER El , } ` DISTANCE TO NEAREST: ,SEPTIC TANK SEWER LINES — DISPOSAL FLO.Q.- PROP. LINE �7` (' FOUNDATION AGRICULTURE WELL'Z20WELL �C PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 03 11 Industrial ❑ Open Bottom LJ Manteca Dia. of Well Excavation_ Dia. of Well Casing Domestic/Private IKGravel Pack ❑ Tracy Type of Casing_5sTZr� Specifications E 11Public ❑ Other ElDelta Depth of Grout Seal Type of Grout ❑ Irrigation Approx..Depth ❑ Eastern Surf ce Seal Installed by Repair Work Done I Type of Pumpu� H•P• State Work Done rV r Well'Destruction ❑ Well Diameter Sealing Material Itop 501 Depth 'Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑, DESTRUCTION 13iNo septic system permitted if public sewer is availabie•within 200 feet.) '-.:Installation will serve: Residence Commercial Other _ �II �, Number of living units: Number of bedrooms til\Character of soil to a depth of 3 feet: t " Water table depth SEPTIC TANK n Type/Mfg. Capacity No. Compartments PKG. TREATMENT PLT. El {{ l •� Method of Disposal •- 'Distance to nearest: �; Well i-•--�.? Foundation l Property Line i t / 17- LEACHING a7-LEACHING LINE ❑ No. & Length of lines 'r Total length/size FILTER BED ❑ Distance to nearest: .Well Foundation Property Line SEEPAGE PITS ;❑ Depth a Size _ Number ± f SUMPS ❑ Distance to near'est:, Well t 7Foundation ~ ` Property Line ° DISPOSAL PONDS .❑ 1 1 A I hereby certify that l 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. -t- y '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, 1 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, I shall employ ipbrsons subject to workman's compensa- tion laws of California." # Xi # The applicant ust call for alVeguired inspections. Complete drawing on reverse side y n t" , Signed Title: Date: FOR DEPARTMENT USE ONLY !� E ate L �� Application Accepted by ;of DAre, pp I IPit or Grout Inspection by - Date ``t Final Inspection b. Date 2 6 ,Additional Comments: , C] Stk 466-Ml ❑ Lodi 369-3621' ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 I Applicant- Return all copies to:.Environmental Health Permit/Services 1601 E. Hazelton Aire., P.O. Box 2009,,,Stk., CA 95201 FEE i INFO AMOUNT DUE, ,, AMOUNT REMITTED rCASH REGEIVED BY ➢1yATE P[ERINIT`"ND. ) J� + EH M24(REV.i0r83) t�5 _ �� ,1�S. � a � y!oiii/ �Slo �s b-2S s EH W26...t.. - t