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r, APPLICATION FOR PE ITC �� SAN JOAQUIN LOCAL HEALT��N�TRICT O, 1601 E. HAZEL TON AVE., STCICXTO.HH FA �`Yv Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM _l�eTSSPd„ p �PR��G N .HEALTH OSE S� H. 1 (Complete in Triplicate) :FERMITAERVICES 1\�� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein desc .This application is made in compliance with San Joaquin County Ordinance No.54.9 for sewage or No. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address L 3 7 City0'1,Lot Size PM Owner's Name PAAIJ �d�t�OT Address 1 3 /7 I CQ A4 1 cel, Phone �C Contractor1411 -0l &19)L Address 3 or S Kf IMS License No. Phone TYPE OF WELL/PUMP: 'NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK I CO- - SEWER LINES —.DISPOSAL FLD. PROP. LINE FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA I' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavati Dia. of Well Casing ❑ Domestic/Private XGravel Pack ❑ Tracy Type of Casing " Specifications 1(p 17 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal .�b�� Type of Grout *rrigation • J Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') i Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installa"tion will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character-of soil to a depth of 3 feet: Water table depth SEPTIC TANK.., ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑., No. & Cength of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line j SEEPAGE PITS ❑ Depth Size Number I SUMPS ❑ Distance to nearest: Well Foundation Property Line .yam•-� �. -- - ..�..._,�,�: +--�+- _-.��- ..-�..�.w-s-w�-.---^� -�+i�---.�.---_-•---...--,,.: �_.�.:i.r.a,.s�.��^�-�,:�� DISPOSAL PONDS ❑ ri 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. r 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."Contractors 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 compensa- tion laws of California." 11 - i The applicant,must call f b requir d i Prc' ns. Complete drawing on reverse side. Signed X c'_' _ �i Title: Date: i 0 t FOR P RTMI�NT USE ONLY Application Accepted by Date Z� *ea Pit or Grout Inspection by W Date Final Inspection by Date Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 82.3-7104 ❑ Tracy 835-63$5 Applicant- R all FqpjOs to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE_ INFO AMOUNT DUE AMOUNT REMITTED "' CASH RECEIVED BYkE PERMIT NO. + EH 13-24(REV.1/a s) EH 14-26 '�C�� ' d