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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT q M PERMIT NO. D 1601 EN , N, CA Telephone (209) 466-67811 q(( I DATE ISSUED oZ f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) he rein Application is hereby made to the,deninocompliancelw,ithlth SanDistrict for a Joaquin Countypermit to Ordinance cNo. 549tfordsewagesorlNoth1862rforewell/pump described. This application is and the Rules and Regulations of the San Joaquin Local Health District. C Job Address W c Subdivision Name n �c Phone U-) Owner's Name Address 49 Phone Contractor's Name License No. ' TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION r PUMPRAS--INSTALLATION SYSTEM REPAIR OTHER ❑ �� DISPOSAL FLD. PROP. LINE SEWER LINES�f� PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK ItG -�— FOUNDATION ' AGRICULTURE WELL OTHER WELL —^ --=-- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t Dia. of Well Excavation Z Industrial Lf op en Bottom ❑Manteca Domestic/Private ` Gravel Pack Tracy Di'aq. of,Well Casing i 4 Y Public Other Delta > Type of Casing �� Irrigation Approx. [] Eastern Specifications Depth Depth of Grout Seal Cathodic Protection , Geophysical ",Type of Grout DAj Other Surface Seal Installed by a Type of Pum H.P. State Work Done Repair Work Done � p Well Destruction U Well Diameter Sealing,Material (top 50') .• _] } "Depth Filler Material (Below 50') i% K: NEW INSTALLATION LJ REPAIR/ADDITION• U�(No,septic'tank or seepage pit permitted if public sewer is TYPE OF SEPTIC WOR available within 200 feet.) 1 Installation will serve:. Residence Commercial _ Other U Number of bedrooms Lot .size Number of living units: i.Water table depth Character of soil to a depth Iof 3 feet: No. Compartments. T e Capacity SEPTIC TANK yp /Mfg -.�! - 1. Method of Disposal + Capacity ] PKG. TREATMENT PLT. E] Type/Mfg r pro erty Line Septic Tank yT�' Distance to nearest: Wel] Foundation p (� De .St Total length/size LEACHING LINE U No. &'Length of lines" Foundation Property Line FILTER BED Distance to nearest; -Wel l- -a , — 6 :Size • Number De SEEPAGE PITS ❑ p,, PropertyLine SUMPS �} Dista=nce to nearest: Well Foundation � DISPOSAL PONDS t t h San Joaquin county I hereby certify that I have prepared this application and that the.work will be done in accordance wit ordinances, state .laws, and rules and regulations of the San Joaquin Local Health District. M Home owner or licensed agent's'signature certifies the following: "I certify that in the performance of the work far which this permit is issued, d shall not employ any person in such manner as to become subject to workman 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 applica ust c 1 for all requ y e inspections. Compl Signed. X ete drawing o se ide. Date: '�3 Title:- - r FOR PARTMENT USE ONLY Area �./7 Stk 466-6781 �C�_„_. Application Accepted by � ' � � T Lodi 369-362.1 Additional Comments:��[t aae,� Manteca 823-7104 Pit or Grout Inspection by _ Date —Date ❑Bracy 835-6385 Final Inspection by lEnvironmental Health Per mit/Services 1601 E. Hazelton Ave., P.O. Sox 2609, Stk., CA 95201 Applicant Return all copiesto: FEE BASE MOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERM/I'T f:NO. r INFOj�- ��{i 1 1 1�wz 500 !' EH 13-24 REV. 10182 14-26