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- --- 074 . APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. NAZELTON AVE., STOCICTON, CA - Telephone 12091 466-6781' PERMIT EXPIRES-'i`YEAR FROM DATE 19SUED' ! (Corriplete'in Triplidate) " " 3` ; a s ,$ � ?" *•� f, ,. ` " Ilcation is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or Install the work herein described. f h app f . r,.,is 4 .' ' made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. r ti r0 F*' r4'Efi� z . L'ot`S+ie r PM Job Address • .�-ir Phone < Address Owner's NameJ" f _ Ll ,9 {� - _ ( IVO Phone Contractor f) � � Address License WELL REPLACEMENT ❑ DESTRUCTION LJE TYPE OF WELL/PUMP: NEW WELL IeiY OTHER ❑ PUMP INSTALLATION SYSTEM REPAIR El4 f SEWER LI ^ES '� DISPOSAL FLD.- PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK 1 OTHER WELL PITS/SUMPS r l FOUNDATION' AGRICULT RE WELL ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing rr ❑ Industrial ❑ Open Bottom � 0?M nteca.}yA' Dia_ of We11 Excavatio L w -Specifications , Type of Casing I [kl5omesticlPrivate il�rayel Rack El Depth of Grout Seal - �a Type of Grout ❑ Public ❑ Other ❑ Delta r ❑ irrigation --Approx. Dept'"_ ❑3 Eastern Surface Seal Installed by Type of Pump H.P. q State Work Done Repair Work Done LlTYp _ \\ Well Destruction ❑ Well Diameter Sealing �aferial {top 50`1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION t7 ti ❑ DESTRUCTION ❑ availabllelwitsystem ne200 feet.) if public sewer is Installation will serve: Residence 4 Commercial Other-' Number of living units: Number of bedrooms ."=9 Water table depth Character of soil to a depth of 3 feet: jCapacity No. Compartments SEPTIC TANK ❑ Type/Mfg f Method of Disposal PKG. TREATMENT PLT. ❑ ;I } Foundation �-•`>P.�-r.°pY Line Distance to nearest: Well _ .. ,�:41 r +, r,,--• Total length/size^` i LEACHING LINE ❑ No. & Length of lines �n a '. `�' •�i�.,:;;, _' I :Prole Line " ` 4'•^ FILTER BED € foundation, Property " ❑ Distance to nearest: Well -1 Number SEEPAGE PITS ❑ Depth Size 1 Foundation Property, � - SUMPS ❑ Distance to nearest: Well Line i DISPOSAL PONDS ❑ _ t I hereby certify that I have prepared this application and that the work wil -be done in accordance with San Joaquin county ordinances, state laws,'and 'I F 1 rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I ceitify that in the laws of ance�of the work for which this permit is issued, I shat not L 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 certify that in the performance of the work for;which this permit is issued,1 shall employ persons subject to workman's compensa certifies the following:., tion laws of California." I . l The applican st Il for all r fired inspections. Complete drawing on reverse side. Date: . y Title:� Signed 1 a. FOR DEPARTMENT USE ONLY Area'" Date Application Accepted by- (� Gq'd' Final inspection by Date Pi r G out Inspection by Date Q dditianal Comments: T ❑ Stk 466-6781 ❑ Lodi 369'3621 El Manteca 823-7104, ❑ Tracy 835-6M Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009,^Stk., CA 95201 r CK RECEIVED 13Y, DATE, PERMIT'NO.' FEE AMOUNT•DUE AMOUNT REMITTED CASH +INFO + EH 1324(REV.V/a 5Y �` EH 14-26 g a OO ..