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APPLIC_ATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT .J 1601 E. HAZEL ON AVE., 574CKTON, CA Telephone (209)466-6781 b. ,,,. 1 , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED v (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 Li 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. 1, City A'" Lot Size PM Job Address `y Address „�r� d Fi'iUone Owner's Name Y �� Ph Contractor Address . License No. f'l+on -A TYPE WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 'SYSTEM REPAIR [3 DISTANCE TO NEAREST: S ANK `. SEWER LINES I 1SPO .:L+�FLD:�� ` PROP: LINE, A _ ,FOIINDA7i'DN:. AGRICULTUREW OTHER WELL = .PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE CONSTRUCTION SPECIFICATIONS1 - i . , [I Industrial ❑ Open Bottom', anteca Dia. Excavation Dia. of Well Casing' F1 Domestic/Plrivate ❑ Gravel P j ❑ Tracy Type of'Casing Specifications \ f ❑ Public er ;. ❑ Delta Depth of Grout Seal Type of Grout 11 irrigation { ��pprox. Depth C] Eastern - Surface Seal Installed by— Repair y Repair Wo one ❑ _Type of-Pump ] H.P. State Work Done— Well Destruction ❑ Well Diameter Sealing Material (top 501 j Depth Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTI N IN septic system permitted if public sewer is 1 i ilable within 200 feet.) 4 Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms Character of Aoil to_a depth of 3 feet: _� Water table depth SEPTIC TANK IJjType/Mfg aIN I QIct No. Compartments :— .. PKG. TREATMENT PLT. ''{M Method of Disposal eDistance to neares erl I,�We l —v&axoria([Agfth]Dtlt Property Line i TJ 1 • rk LEACHING LINE ” ❑ ."No.'& Length of lines - � p otal length/size FILTER BED ❑� Distance to neare.:Y L Jl() `..A F Q �1rat �arT Property Line SEEPAGE PITS ❑f—Depth Size Number SUMPS ❑ Distance to nearest: . Well Foundation Property tine 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."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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must 11 for all required i pections. Complete drawing on reverse side. Signed Title: Date: 5 FOR D PARTMENT USE ONLY G [] ' Application Accepted by Date �3 6 Areay) Date Pit or Grout Inspection by Date Final Inspection _ / - Additional Comments: 'S { ❑ Lodi 3 ❑ Stk 466-6781 369-3611 ❑ Manteca 823-7104 ❑ Tracy 8356385 r 1 N!!, I1is ?�h )y1l�sR-t, , M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520 hL nFEE ,' IAMOUNT DUE AMOUNT REMITTED CK RRRECEIVED BY DTE PERMIT NO.+ EH13-24rREV.':/H5) EH 14-28