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r APPLICATION FOR PERT Z" .. SAN JOAQUIN LOCAL HEALTH DISTRICT:. moo,. 1601 E. HAZEL T ON AVE:;-S-TOCKTON, CA Telephone (2096M-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 Joaquin County Ordinance No.549 for sewage or No. 1B62 for well/pump and the Rules and Regulations of the San Joaquin F Local Health District. ` Job Address C�r� s f city Lot Size v -t-s PM _/�I - o p Owner's Name �Q r Address v Phone O� r Y Contractor Address a St l n(17 License No. Phone_ TYPE OF WELL/PUMP:. NEW WELL ❑ WELL-RE-PLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ T� SYSTEM REPAIA O OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL. OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION"SPECIFICATIONS ElIndustrial ❑ Open Bottom L1Manteca Dia. of.Well-Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack -❑ Tracy Type of Casing _ Specifications I'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I E Irrigation _..Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. . State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 VN TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITIONK DESTRUCTION l I (No septic system permitted if public sewer is / available within 200 feet.l — Installation will serve: -Residence commercial— Other Number of living units: 1 Number of bedrooms 3 1 �• Character of soil to a depth of 3 feat: VkAyLvRJSJ Water table depth SEPTIC TANK ; o4 ❑ Type/Mfg' Capacity No. Compartments PKG. TREATMENT PLT."❑ Method of Disposal Distance to nearest: Well Foundation Property Line _ I LEACHING LINE fle,No. & Length of lines Total length/size ' FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number t SUMPS LZ Distance to nearest: Well Foundation Property Line { 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." Contractoes hiring or sub-contracting signature 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 applicant mu c ll for all to ad ins ctions. Co'cl mplate drawing on reverse side. Signed. Title: Date: DEPARTMENT USE ONLY a Application Accepted byCDC,.,, Date _ �� Area Pit or Grout Inspection by Date Final Inspection by �' �""`� Date ! f f # Additional Comments: '1& � -1. El'ce 15`1-33 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ MaNta 823-7104 ❑ Tracy 835-6385 _ Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,,P.O. Box 2009, Stk., CA 95201 4-4- FEE 4MOUNT DUE AMOUNT INFO REMITTED RECEIVED SY _ DATE PERMIT NO. -10 -00 � {{CASH + EH 13-24{REV.1/A 51 O fv"� (� DO L�(� 1 A0 tr-I3 EH 1429