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r 5 APPLICATION FOR PEll,, r � SAN JOAQUIN..LOCAL HEALT:r.H.DISTRICT 1601 E. HAZE T ON AVE., STOCK N, CA No WF—LL Telephone (209) 466-6713 ` 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District: - I- :, ,> Job Address City Lot Size we) PM Owner's Name Address Phone ` y ;azlhz;�� Contractor ! ddress /^:/!' License'lV0. �iJ ` ,Phone TYPE OF WELL/PUMP: WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ~ " PUMP iNSTALLA © - SYSTEM REPAIR D OTHER❑ DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGR TURE WELL OTHER WELL PITS/SUMP$ INTENDED USE TYPE OF WELL PROBLEM AREA_ CO U ❑ Industrial ❑ Open Bottom ❑ Man Dia. of Well vation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications I ❑ Public clpawil ❑ Delta Depth of Grout Seal Tide of Grout ; O IrrigationApprox'D6pth O'Eastern "" "Surface Seaf`Installed"by IN Repair Work Done 0 .`Type of Pump W.P. '. State Work Done r Well Destruction ❑ Well Diameter Sealing'Material (top 561 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK::, NEW INSTALLATION ❑ REPAIR/ADDITIO)SL O D TRUCTION ❑ (No septic system permitted if public sewer is fV) vailab within 2D200, f�eeetJ Installation will serve: Residence_ Commercial_ Other f. Number of living units: Number of bedrooms � j ��.• Character of soil to a depth of 3 feet: VVater table depth SEPTIC TArNK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. p Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0—Disiarice to nearest:—Well'—-' Foundation �_Propeity Lina SEEPAGE PITS ❑ Depth Size - -; Number SUMPS =. ❑ Distance to nearest: . Well' j Foundation Property Line DiSPOSAL'PONDS ❑ 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." Contractor's hiring or sub-contracting signature i 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." The applican ust call for required i spections. Complete drawing on reverse side. Signed Title: Date: "�'v r �F!! PARTMENT USE ONLY Application Accepted by .may Date Area Pit or Grout Inspection by ``f� Date Final Inspection by Date Additional CommantsA�949,01� `>F69a 05t7-�_ ❑ Stk 466-6781 --`❑ Lodi '369-3621 121 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Enviro6mental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 { INFO FEE AMOUNT DUE `. AMOUNT REMITTED CA5H RECEIVED BY DATE PPEERMIT'NO. t l M24(REV.t/s5l �v � *'- L,! �i EH 14-28 / ,p� /