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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 EHAZELTON AVE., TON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED P (Complete in Triplicate) 1862 for well/pump and the Rules and Regulations of the San Joaquin 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 o Local Health District. PM------ City ��a Lot Size I try AysT►N R D Job Address ^ c Phone �,ddress 8.2s�bs8�/ Owner's Name �bK W 2(J-37113 -.-Phone I.S® &.;-(-CCAl A04e- License No. e„ (tG,%L Q.. Address❑ _ WELL REPLACEMENT ❑ OTHER ❑ DESTRUCTION El Contractor�— NEW WEAL TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ PROP. LINE PUMP INSTALLATION ❑ SEWER LINES --------- DISPOSAL FLD._--- PITS/SUMPS -- DISTANCE`TO NEAREST: SEPTIC TANK --- - — — AGRICULTURE WELL OTHER WELL— FOUNDATION ELL— FOUNDATION ------- E AT WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing TYPE INTENDED USE ❑ Manteca Dia. of Well Excavation Specifications n Industrial El Open Bottom Tof Casing — ❑ Gravel Pack ❑ Type Tracy Type of Grout ---- El Domestic/Private n Delta Depth of Grout Seal n Public Ll Other Surface Seal Installed by Approx. Depth l I Eastern State Work Done :— I I Irrigation — H.P. Repair Work Done ❑ Type of Pump Sealing Material (top 501 Well Destruction ❑ Well Diameter Filler Material (Below 501 Depth tic system permitted if public sewer is available within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATIONd REPAIR/ADDITION LI DESTRUCTION l 1 (No sep � _---- Installation will serve: Residence ✓ Commercial ther_ Water table depth Number of living units: _J_ Number of dr�o s---- C�O No. Compartments Character of soil to a depth of 3 feet: ❑ Type/Mfg Method of Disposal SEPTIC TANK PKG. TREATMENT PLT. ElDistance to nearest: Well _--- Foundation— ---- Property Line � ® Total length-1— No. & Length of lines Property Line_---- LEACHING LINE Foundation_ ---- FILTER BED ❑ Distarice to nearest: Well_--- Number l 1 Depth Size Property Line_---- SEEPAGE PITS Foundation_— state laws, and SUMPS Ll Distance to nearest: Well_--- DISPOSAL PONDS have repared this application and that the work will be done in accordance with San Joaquin county ordinances,s� d I shall not I hereby certify that 1 h P I certify that in the performance of the work for which this pe azure rules and regulations of the San Joaquin Local Health District. arsons subject to workman's comp Home owner or licensed agent's signature certifies the following: r which this permit is issued,1 shall employ P such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature ensa employ any person in Tons. ance of the work certifies the following:"I certify that in the pe tion laws of California." The applicant must call for all�iireAli Complete drawing on reverse siti pate: �� Title: Signed X V FO DEPARTMENT USE ONLY � Area Date r Application Accepted by IJ Dat Final Inspection by Date_----- Pit or Grout Inspection by Additional Comments: 11 ❑ Manteca 823-7104 ❑ Tracy 83 5 �'i/i �,��/ ` 01 11 ❑ Stk 466-6781 ❑ Lodi 369 3621 azelton Ave. 0• �i? T tom'/ .9D tF� �✓l s 0 Applicant Return a copies o: E vjronm�tttal Heal,4 e�it/Suer lc�4 1�r� � , , r� ,C jcz` y� fCf� �f� � cc�/e A✓ B ��c p/,LTC✓. iY�/ /"'- DATE PERMIT'NO. B BECIgd1E RECEIVED BY FEE AMOUNT DUE AMOUNT REMITTED CASH INFO /,.�0 �©^Vv �� + EH 13-24(REV ��Hel � 1 EH 14-26