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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT a� 1601-E-!-HON-AVE-!- IN Telephone (209) 466-6781 �Q PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1��1. 3 g9(,�� (Complete in Triplicate) cb,N f� �� 0�g5S oA 4 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work here I, application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules aT4413� tions of the San Joaquin Local Health District. 3246 rASi N i Sf. TOci<io n1 Z Job Address �iZeelaCity 5 Lot Size" ��r oO v �{ PM Z LII0 C1+10 as Q X4140 N Owner's NameCH JPO q• S/}• I N Address 54IJ Q/}H 0 N C4 YSSS 3 Phont��js ContractorF--rl•LNAUCr WIELL 3s2 1•t'f•N6Address C01VC K.D G4 434 51$ License No.k94 39 0 Pho4(5 685- CC 13 TYPE OF WELL/PUMP: - NEW WELL WEILL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 11 SYSTEM RE AIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES 50 DISPOSAL FLD. PROP. LINE !� FOUNDATION _ AGRICULTURE WELL- OTHER WELL154 A2 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. ofWell Excavation i h• Dia. of Well Casing • W E] Domestic/Private - Gravel Pack^ LlTracy Type of Casing—PVC Specifications 0•0(0 >lot– N � f'l Public ❑ O her X Delta Depth of Grout Seal �C Type of Grout I I I�ri4tatipn •V p�+�pprox, Depth I I Eastern Surface Seal Installed by'KVIt,NAUCT W45i� .D2iLtiNG _ (� I He1'+IT, !I r V , parr Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50.1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION 13 DESTRUCTION I i INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial --Other �1 } Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments b PKG. TREATMENT PLT. ❑ _ Method of Disposal Z Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS Ll 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." 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." rf� 4 The applicant mus 11 II requ� d 'inspections. Complete drawing on side. Signed X eJU� ,Title: I iJ �a cJ ✓� Date: FOR DEPARTMENT USE ONLY !/ Application Accepted by Date Area 7 �J j! Pit o ou Inspection byDate a Final Inspe tion by Date - I Additional Comments: ❑ Stk 466-6787 ❑ Lodi 369-3621 ❑ Manteca 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 FEEj INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY /DATE PERMIT NO. i + EH1429 3-24 I R EY.i i n h)T EH 1 } �a.7 ,O 1