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.. APPLICATION FOR PERMIT SAN .IOAQUlN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE. -- . Telephone (209) 466--6781 TON' CA PERMIT EXPIRES 1-YEAR FROM DATE ISSUED` `by,7Yi�:7 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct ' made in compliance with San Joaquin County Ordinance No.549 for sewa e y ,Local Health District. E and/or install the work herein described.,This application is �J �^ ♦ ,kyr.= g °r No• 1862 for well/pump and the Ryles and Regulations of the San Joaquin Job Address r b4zce!C ij R`r city' -S Owner's Name 7 �� CJEr! �' Lot Srze _l,- IUD O��'Mo PM" Address n C Hr S61/ e�- U ':: .;.. Contractor C Phone Address � S 9s-Zo/ TYPE OF WELL/PUMP: License No. NEW WELL ❑ WELL REPLACEMENT.❑ —Phone Z� DISTANCE TO NEAREST: SEPTICPUMP TANK SYSTEM REPAIR ❑ OTHER INSTALLATION [I DESTRUCTION ❑ —� SEWER LINES [1LZL- FOUNDATION ---- � DISPOSAL FLD. PROP. LINE AGRICULTURE WELL INTENDED USE TYPE OF WELL PROBLEM AREA PITS/SUMPS 11 IndustriOTHER WELL al �� . .CONSTRUCTION"SPECIFICATIONS ❑ Open SOttom;d t" Manteca " ❑ Domestic/PrivateDia. of Wel! Excavation- 0 Gravel Pack i ❑ Tracy T ;' Dia. of Well Casin ❑ Public El Other j Type Casing {L i g ❑ Irrigation 1 11 Delta Depth of Grout Seal Specifications ' ---Approx. Dep, ❑ Eastern f — Type of Grout Repair Work Done ❑ r Surface Seal'+lnstalled"by� Type of Pump _:y H P� Well Destruction ❑ Well Diameter.` { State Work Done 1t g Sealin Material (top 50') D p s r, TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADD1iTION(❑lo DESTRUCTION ' # rl No septic system permitted if public sewer is { Installation will serve: Residence! 1C6mmercial ; available within 200 feet.l Number of living units: %lC Other Number of'bedroII� � Character of soil to a depth of 3 feet: -- S SEPTIC TANK l r ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ :' Capacity__. No CompaRments r Distance to neo est: Well Method,of Disposal FoundationProperty Line i LEACHING LINE ❑ No. & Le g h of lines FILTER BED ❑ Distance to neatest: Well Total length/size Foundation Property Linej i SEEPAGE PITS ❑ Depth -- r ) ~ SUMPS Size Number ❑ Distance 6 6earest: Well DISPOSAL PONDS ❑ fes` Foundation Property L e I hereby certify that I have prepared this application and that the work will be done in accordance withASa Joaquin county ordinances state rules and regulations of the San Joaquin Local Health District. 4 Home owner or licensed agent's signature certifies the following: / 1� to laws, and the employ any person in such manner as to become subject to workman's compensation laws of California."Contractor s hiring or sub-contracting signature Performance of the work for which this permit is issued, 1 shall not certifies the following:"I certify that in the pert mance of the work for which this permit is issued-;I shall employ tion laws of California." ; r� p y persons subject to workman's compensa- The applicant must c r II required ins tions. Complete drawing on Signed re r side. . I - ' Title: Da 7 te: FOR DEPARTMEN7rUSE ONLY" Application Accepted by Date_ �J�rJ S Area ' Pit or Grout Inspection by 1 Date Final Inspection by D—� Additional Comments: _ - �'' - � _ k Date O ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca M-7104Tracy pY 5-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E❑Hazelton jAve., P.O. Box 2009, Stk„ CA 95201 I FEE INFO AMOUNT DUE AMOUNT REMITTED i 13-24{REV.1/B5l CASH RECEIVED BY DATE PERMIT`NO• 1 F - 1426 . x r