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-fin• `'" x`` APPLICATION FOR PERMIT til ` SAN JOAQUIN LOCAL HEALTH DISTRICT . . •� 'k � 1601 E. HAZEL i ON AVE., S70CKTON, CA I 7eiephone (209)466-6781 U PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 (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 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 City Lot Size PM I�. Owner's Name 'O ` Address ` Phone + d Contractor _ �4Lft r Address, V 141-t li'CNof License No. 2_ Phone 16 L, TYPE OF WELL/PUMP: NEW W L WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLAT� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK I r SEWER LINES DISPOSAL FLD./�/y- PROP. LINE ` \ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIOft ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excav 'on Dia. of Well Casing �. amestic/Private Gravel Pack 'Tracy Type of Casing Specifications C/i fl PublFc ❑ Other l Delta Depth of Grout Seat j Type of Grout i ` I Irrigation --Approx. Depth b I Eastern Surface Seal Installed by k Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 - T Depth Filter Material (Below 501 s TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer rs available within 200 feet.) Installation will serve: Residence_ Commercial_:. Other Number of living units: Number of bedrooms C Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg /l Capacity E No. Compartments PKG. TREATMENT PLT. ❑ Method of'Disposal Distance to nearest: Well Foundation Property Line 1. LEACHING LINE ❑ No. & Length of lines ` Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line4 { SEEPAGE PITS I'] Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation `Property Line DISPOSAL PONDS Cl 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. –n 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 st II for 1111 reire inspections. Complete drawing on/reverse sidle. g Signed X Title: i r � F EfVT U5E ONLY ! Application,Accepted by Date LD—t-1 . Area Pit or rou Inspection by 47Date Final Inspection by Date 4 Additional Comments: ❑ Stk 466-6781 0 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 f- FEE UNT DUE AMOUNT REMITTED WCK* RECEIVED BY DATE PERMIT NQ. INFO i / �� ♦.EH 1 -241AEV.r/H 5f / 0— ��"� � 00 +g EH 144-29 � 1 '