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APPLICATION,FOR PERMIT , r SAN JOAQUIN LOCAL HEALTH DISTRICT F 1601 E. HAZELTON AVE., S'TOCKTON, CA f Telephone f209) 4W-6781 PERMIT EXPIRES 1 YEAR FROM DATE 1ISSII A, (Complete in Triplicate) r Application is hereby made to the San Joaquin Local Health District fora made in compliance with San Joaqui ounry Ordi once No.549 for sewage or Na. 1862 for well/pump and the Rules and Regulations of the San Permit to construct and/or install the work herein described. This application isr Local HeaI Dist9'ct. p p er ` �--�Y.- Joaquin Job Address �! tl City Lot Size '1=T_i /L(�*S�..PM a Owner's Name 'Z' Address .1 //yy Phone 33 -3 � 12, Contract r-A. l: Address l'd TYPE OF WELL/PUMP: { License No. �l o NEW WELL ❑ Phone WELL REPLACEMENT ❑ DESTRUCTION [JPUMP INSTALLATION ❑ SYSTEM REPAIR ❑ e DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ --� SEWER LINES OTHER ; - �� OTHER FLQ. , " -- --- �- -FOt1NDAT10N.. _-__ . .-_ AGRICULTURE�WEL-L----._ - PROP. LINE INTENDED USE -WELL ,"'-' -PITS/SUMPS- TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottomf f ❑ Manteca r - ❑ Domestic/Private Dia.,of Well .Excavation Dia. of Well Casing f k �.; 46 ❑ Gravel Pack ❑ Trac -Type �` �� .y�� ❑ Public y Type of Casing - y _ _ El Other ❑ Delta Specifications , (5—Irrigation ---�--•- --�---.;�. , ,.Depth of Grout Seal , T Y _;Approx, Depth ❑ Eastern —Type-of ype-of Grout ^ Repair Work Done ❑ T Surface Seal Installed by �} ype of Pump H P Well Destruction ❑ Well DiameterState Work Done'— Sealing Material (top 50') _ Depth Filler Material (Below 501) �4 TYPE OF SEPTIC WORK: NEW INSTALLATION AEPAIR/ADQITION ❑ DESTRUCTION ❑ {No septic system permitted if putt c sevyer is ��f r Installation will serve: Residence Commercial_ available within 200 feet.) I ther Number of living units:—I— Number of be rooms /p Character of soil to a depth of 3 feet: "I t SEPTIC TANK .Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ Capacity Q8 No. Compartments Method of Disposal A, G Distance to nearest: Well;I Foundation (/ Property Line _ --�s� LEACHING LINE �,frl a.3 No. & Length of lines FILTER BED " �- .Total length/size. ❑ .Distance to nearest: Well / Foundation f - _ —14CL_— Property Line A SEEPAGE PITS ❑ DepthSize o f i t t SUMPS N mumu berms ❑ .Disj ltance to nearest: Wep Foundation s' d DISPOSAL PONDS Clr + r , Property Line ! hereby certify that I have prepared this application'and that•the work.will beJ al rlpne 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 followin g: "I,certify that in the performance of the work for which this permit is issued, I shall not certifies esthe following: i loy ny person "I certify that the performance of n such manner to become subject to watkmarl's compensation laws of California."Contractors hiring or sub-contracting signature , g: .the work for which this permit is issued, I shalt em io tion laws of California." p y persons subject to workman's compensa- The applicant mu II for all'req ed i spections. Complete d�wing on r<everstsid Signed X 4�_7itle: Date: L i FOR�DEPARTMIENT USEONLY Application Accepted by TMDate Tb Pit or Grout Inspection by � -� j T Date Area Final Inspection by -7 F ` -7 I Additional Comments: "' ` -""` -.� Date ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 # Applicant- Return all copies to: Environmental Health Permit/Services 1601 E❑Hazel on Tracy A�veP50. Box 2009 Stk., CA 95201 ! FEE AMOUNT DUECK INFO AMOUNT REMITTED RECEIVED BY �3 CASH DATE PERMIT`NO. ` # + EH14-24fREV.i>f351 �}f�r(�� q g EH 1428