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J &166C APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 63 1601 E. HAZEL—JON-.A� �/E., STOCKTOfV, CA V aJUN 1 400 Telephone (209) 466-6781 Al1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j I r'NVIR0NMENZALHEALP (Complete in Triplicate) f Application is heieby mddre 176--& d `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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address /l/I J . iF CKIn+�'A + City of Size PM /X 14' QG Phone Owner's Name ,&JI `{n Address f,�L Contract Address Z. License No.I DZ37Phone VV TYPE OF WELL/PUMP: I� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINET. 1 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-Casmn ❑ Domestic/Private ❑ GrF vel Pack ❑ Tracy Type of Casing S 1 ications FI Public n Other F1 Delta Depth of Grout Seal ype"of4Grout I I Irrigation N'�Approx. Depth I I E stern Surf ac Seal Installed by .% k f. � _ - 7`` 4 4 Repair Work Done lTypei`of Pump _�. H�P• State Work Dol/e Well Destruction El Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1 l — TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIRIADDITION l I DESTRUCTION I i INo septic ystem'permitted if public sewer s Ifavailable wi in'200 feet.]' s Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: -Water table depth f5 i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ I� Method of Disposal piistance to nearest: Well Foundation - Property Line all, l� LEACHING LINE ❑ No. R Length of lines Total length/size f FILTER BED ❑ Distance to nearest: Well Foundation Property Line q. _SEEPAGE PITS { I Depth I Size r/ - --Number - -- _. SUMPS o pistance to nearest: Well /,Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work Q11 be%done in accordance with San Joaquin courity ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. :'s'` Home owner o nse ent's signature certifies the following:4:1 certify.that in the performance of the work for which this`pe�mi[is issued, I shall not employ any rson insuc manner as to ecome ject to workman's compensation laws of California.;' Contractor's hiring or,.sub-contracting signature certifies t following: "I rtify that i16ce of the work for which this permit is issued;^I shall employ persons subject to'workman's compensa tion law of Calif nia." ;I�, r \ �� /^ # The ap icant t f r all r rawlrig on e e side V ' i1M�[�i'L Signed -. Title: `� � Date: OR DEPARTMENT USE ONLY Application-Accepted by/11 �,-v Date R �^Z� Areaill p Pit or Grout Inspection by Date Final Inspection by Date (() �AdditionalyComments; I� Q Sw, 466-6781 ❑ Lodi 369-3621 L1 Manteca 523-7104 ❑ Tracy 835-6385 Applicant,- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.i.O. Box 2009, Stk., CA 95201 l I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE i PERMIT NO. INFO CASH +.EH 13 �t H 57 I - �—�./9 EH 14-2d