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k S r _ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE:.i ON AVE., STOCICTON, GA - Telephone 12091 466-67814 " 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/pump and the Rules and Regulations lob the San Joaquin Local Health District. Job Address /111 A7G IK CityS� Lot Size 2 PM Owner's Name Ad ress Phone -- CT sotscs _s,ZZ�e yGs g� i ` Contractor + r Address ,S Tac ft171�icense No y�5a Phone 1 TYPE OF WELL/ UMP: NE WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION © ' SYSTEM REPAIR ❑ OTHER S"t r a`�r DISTANCE TO NEAREST: SEPTIC,TANK SEWER LINES ISD r DISPOSAL FLD.1-" /` PROP. LINE I FOUNDATION _/40 7 AGRICULTURE WELL OTHER WELL. r PITS/SUMPS S - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' ❑ Industrial n ❑ Open Bottom D Manteca Dia. of Well Excavation _. Dia. of Well Casing=, --. ❑ Domestic/Private ❑ Gravel Pack ED 1i Type of Casing Specifications f'] Public µ F1 Other C] Delta Depth of-Grout Seal e. Type of Groutµ "� m I I Irrigation b -.Approx. Depth I I Eastern r, Surface Seal-Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth Filler Material (Below 501 - �, TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is - available within 200 feet.) W.- -.,_T___.-.•- Installation will serve: Residence_ Commercial_ Other. Number of living units: Number of bedrooms �} 'Character of soil to a depth of 3 feet: Water table depth-- S EPTIC epth- SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 111 SE=EPAGE PITS I 1 Depth Size Number \3) tivh�l SUMPS Ll Distance to nearest: Well Foundation Property Line 4 DISPOSAL PONDS ❑ 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 call for all re ired ins ctions. Complete drawing ory reverse side /Z Signed X Title: 744 �G Date: v[1 6~1 FORD M E ONLY �7 Application Accepted by Date r y' Area Pit or Grout Inspection by Date 8- Final Inspection by Date Additional Comments ❑ Stk 466-6781 0 Lodi 36.9-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY DATE PERMIT NO. INFO CASH EH 13-24(REV.i/KW EH 14.28