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*r, - APPLICATION FOR PERMIT " t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKT.ON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) RAN�ffC Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of 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 of the San Joaquin Local Health District. Job Address O �Yf} r� L y City rs✓/ Lot Size 311 X 3 7 Y PM Owner's Name S�fv ri'OA4014/ G14tVST c Address /'�+©�2 ltf�vy` .� al.Kt'd�'Phone -e-YP Contractor's Name nA: "0�License-it1o. -iy Phone TYPE OF WELL/PUMP: NEW WEL'L"'O WELL-REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ �- SYSTEM REPAIR ❑ >' OTHER ❑ Q W OISTANCE TO.NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLD. - PROP:LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing w ❑ Domestic/Private ❑ Gravel Pack © Tracy Type of Casing f—!�Specifications 11Public ❑ Other ElDelta Depth of Grout Seal #' ype of Grout ❑ Irrigation ----Approx. Depth E3 Eastern Surface Seal Installed by � i Repair Work Done ❑ Type of Pump H,P. State Work Done ` Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑• INo septic system permitted if public sewer is available within 200 feet.) ,Installation will serve: Residence Commercial Other *Number of.living units: Number of bedrooms Character of soil to a depth of 3 feet: C e- e7 Water table depth 60 SEPTIC TANK, Type/Mfg ff Capacity /.?D (a No. Compartments PKG. TREATMENT PLT. ❑ f 0 Method of Disposal rr• +� �'f!11�' Distance to clearest: Well Foundation ft} Property Lirae�+ ! E - LEACHING LINE I No. & Length of lines 7s� 'Total length/size f FILTERxBED ❑ Distance to nearest: Well 4tW Foundation /D Property-Line- J7 SEEPAGE PITS (Depth �� Size _i Number SUMPS ❑ Distance to nearest: Well. C � Foundation /V ` Property Line DISPOSAL PONDS ❑ i 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. I 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." J The applic ust call for all re uired inspections. Co_mplete.drawing-on_reverse_side. Signed / Title: , Date: FOR DEPARTMENT USE ONLY Application Accepted by � 4Dater vr� Area Pit or Grout Inspection by � f � Date �o� Final Inspection by { Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy,'7635-6385 f Applicant- Return all copies to: Environmental Health Permit/Services 1601.E'' azelton Ave., P.O. Box 2009, Stk., CA 95201 $~ ' 't/ FEEAMOUNT DUE.-+ AMOUNT REMITTED CK# RECEIVED BY DATE PERMVT`NO. Vu INFO �- CASH +EH 13-24{REV.10/83) �..L-. tip �j�a �q-7,tf F EH 14-26