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APPLICATION FOR PERMIT OCT 291984 SAN JOAQUIN LOCAL HEALTH DISTRICT ®�1 1601 E.,HAZELTOIV, VE.;,STOCICTQN, CA SAN 10AQUIN LOCAL Telephone 12091 466-6781 HEALTH DISTRIC"T" .PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k r ' 6 {Complete in Triplicate} r. 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 A�ECity L Lot Size . PM Qe- Y Owner's Name Address' I/6 1�A /PISS/1 /�1� Phone +D Contractor's Name !L Licenseo. / 7a.s 5 / Phone �6 TYPE OF WELL/PUMP: NEW WELL ❑ ' 441' '"WELL REPLACEMENT ❑ DESTRUCTION ❑ _!/ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER "/4'l N 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 Vdustrial El Open Bottom ❑ Manteca Dia. of Well Excavation ° Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing a Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State,Work Done dpi Well Destruction El Well Diameter Sealing Material (top 50') _ Ix � p e je Depth I t=iller Material (Below 50') x# TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION'❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercials—Other t. Number of living units: Number/f bedrooms Ui Character of soil to a depth of 3 feet: ter Water table depth o SEPTIC TANK ❑ Type/Mfg 1 _ Capacity No. Compartments PKG. TREATMENT PLT. ❑ ' '+r ; 1 — Method of Disposal Distance to nearest: Well Ftoundation m Property Line LEACHING LINE ❑ No. & Length of line/ Flj Natal length/size FILTER BED ❑ Distance to nearest: Well OoundaA Property Line SEEPAGE PITS ❑ Depth Size N�mbw 1 -- _,;..._---7__.�_.- f� SUMPS ❑ Distance to nearest: Well Foundation Property Line U+ DISPOSAL PONDS ❑ - •� — —"'f 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. r Home owner or licensed a ant's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not r employ any perso such ner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature certifies the fol ing:"I certi that in the performance of t work for 'ch this permit is issued, I shall employ persons subject to workman's compensa- tion laws of alifornia." a The appli nt must call r I require ns o dr ing on reverses ;Signed POR DEPARTMENT USE ONLY / Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection . Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 1- ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,.iP.O. Box 2009, Stk., CA 95201 IFEENFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED`I3Y DATE PERMIT"NO. + EH13-24(REV.10183) � EH 14-28 !Y`�