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SQ APPLICATION FOR PERMIT 67 SAN JOAQUIN LOCAL HEALTH DISTRICT " 1 1601 E. HAZE i ON AVE., STOCKTOW 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'IJoaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin y Local Health District. I M 1 r Job Address 76 �j~/s�®� ` City a�4� Lot Size C PM IIN �p' [�jj T� 9 2 Owner's Name Address��]/3�574x1'- !/:. �;i" ' _ L�/'I-� Phone '+I Contractor 6e 7/// C 6 Address Ax a97 I icense No. 6 4�� Phone 9 am TYPE OF WELL/PUMP: �� NEW WELL WELL REPLACEMENT.[,] DESTRUCTION ❑ '. ~ PUMP INSTALLATION X SYSTEM EPAIR ❑ r'"`f O.THER ,❑DISTANCE TO NEAREST: SEPTIC TANK 20? SEWER LINES , ?29 ---D POSAL FL PROP. LINE n FOUNDATION AGRICULTUREWELL" -w.-OTHER WELD PITS/SUMPS-- INTENDED USE TYPE OF WELL PROBLEM AREA-'CONSTRUCTION SPECIFICATIONS)t"'-., ❑ Industrial ❑ Open Bottom ,'X-Manteca Dia?of Wall Excavation Dia. of Well Casing Domestic/Private Gravel ❑ Tracy Typ oe f Casing-- PY[_ Specificationsr/ 171 Public I 1=1�01her n Delta Depth of Grout Seal c Q Type of Grout,&d4)-P I 1 Irrigation--A;a hl.-Approx. Depth -1 I Eastern ii Surface Seal Installed by I `Repair Work Done ❑ Type-of"Pump ,�' , ry,P. t State Work Done _ Well Destruction—E] Well Diameter Sealing Material (top 50') _ Depth) Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR./ADDITION I I UDESTRUCTION I i (No septic system permitted if public sewer is 11 1 available within 20 0 feet`) Q I Installation will serve: Residence_ Commercial— sOther t 3 t . I �# Number of living units: Number of bedroomsr 1, �� -� •sgi � 3 v Character Of soil to a depthlof,3 feet: Water fableeptfi SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments € PKG. TREATMENT PLT. ❑ t i" -..e- ..�...«,- Method of Disposal Pistance to nearest: Well Foundation Property Line 4 LEACHING LINE Do. & Length of alines I—: - ,f r t Total length/size I f:. 11. r FILTER BED EJ Distance to nearest Well Foundation Property Line #t i SEEPAGE PITS l I Depth '� Size Number 'I t I SUMPS 0 •Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have pfep4ed 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 toTbecome subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature l certifies the following: "I certify that in the performance of the work for which tHis-permit is issued, I shall employ persons subject 10 workman's compensa- tion laws of California." i The applicant m j call for allirequi ed in ctions. Complete drawing on reverse side. Signed X 'rit D91 /tea C�p J�ifle: � _ •Date I ORD PARTMENT USE ONLY � C W Application Accepted by Date = Area it i Pit or Grout Inspection by - Bate Final Inspection by '+ Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 R Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,_Stk., CA 95201FEE . INFO AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24 IREV.i m51 EH 14-26