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r * J APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCICTON, CA F `�V✓✓✓ Telephone (209) 466-6781 rl'` n 00- JJ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED A (Complete in Triplicate) i ! Application is he,eby 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 West Corner of El Sanjon & Oakwi]AIp Stkn Lot Size 4500 ft PM Za ari.s Man Address Phone �! Owner's Name � , s ' Contractor Address License No. fl—1 HPhone — TYPE OF WELL/PUMP: NEW WELLgX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 14" 400 ft deep ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 361r Rore Oia. of Well Casins3 L. ❑ Domestic/Private ,Gravel Pack ❑ Tracy Type of Casing StPPI. Specifications ,250 Public 1715 Other" F Delta Depth of Grout Seat 50 ' Type of Grout_C)--.S ark _ t 1 Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by—otberc _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 4 TYPE OF SEPTIC WORK: NEW INSTALLATION ('i REPAIR/ADDITION i I DESTRUCTION ( I (No septic system permitted i_f public sewer is + s' E' % Co . r.t 't' U t t:' i S,-J 11 .1 k.�1' i. i.CIE- 1i1 k ilavailable withint200'feet.i'I Installation will serve: Residence_ Commercial_ Other i Number of livinglunits: !q.-! umber,ofl bedrooms r '# Cirri€1i ,='.aJs C� irJt�E? i.J 'D2? 91. 72 Character of soil to a depth of 3 feet: Water table depth I SEPTIC TANK;�t r ,� y.O.:g Type/Mfg w Capacity No. Compartments r/, f PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: `Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines U Total length/size ? FILTER BED ❑ Distance to nearest: Well Foundation Property Line j. 400 te dk-ep 1h Br,r� sl.; i c�110 SEEPAGE PITS I i Depth Size Nurriber SUMPS ;.Ll ;Distance to nearest: Well Foundation Property Line �i 't DISPOSAL PONDS ❑ J d;: hereby certify that l 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 Di§trict. kHome owner or licensed agent's signature certifies the following: "l certify that in the performance of the work for which this permit is issued, I shall not t 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 c 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 Calif pi. ' The applican t ar r ire Hsps io . Complete drawing on reverse side. Signed Title: V P C A Y M Date: 5" Mayr S 9 FOR DEPARTMENT USE ONLY Application Acce'pte'd b { "Date Area 1 r 2.. Pit or Grout Inspection byDate Final Inspection by Date V - _ Additions! Comments: ,J !! ❑ Stk 466.6781 ❑ Lodi 3 ❑ Manteca 823-7104 ❑ T,'Ay 835-6385 l Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK 9 RECEIVED BY DATE PERMIT NO. INFO CASH +.EH 13-24(REV.t/x 51 '- 7c) +�7�7 EH 14-26 4