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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOC,KTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED /� ' (Complete in Triplicate) Pox C Application is hereby made to the.5an Joaquin Local Health District for a permit to construct and/or install the work herein described. TMs 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 I Local Health District.A, 1 I �Z� t/ J Job Address r l �6 S V r n i ciitty a+ �� ' Lot Sizew PMo 7 1 N f �.3 ! J c91 041 t�.Z � Ic� �1 Q�t'G Ph on Owner's Name A LAN A Address -%> i I �A A.I ee,v l % // (. c� License No. 7 g q`? Phone ?X3 -4D6_ I Contractor's Name . i TYPE OF WELL/PUMP:, ? NEW WELL j$j WELL REPLACEMENT ❑� DESTRUCTION 1:1 PUMP .INSTALLATION X SYSTEM � EPAIR Ll 1--" �- OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES ��.� DISPOSAL FLDIC PROP. LINE �5 FOUNDATION _a` - AGRICULTURE WELL. OTHER.WELL �o� PITS/SUMPS INTENDED USE TYPE OF WELL- PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial Dia. of Well Casing ❑ Open Bottom Manteca Dia. of Well'Excavation �. . _'In V . -CIS 6S APPSpecifications Dk Domestic/ Private Type of Gravel Pack El Tracy . 9— ( m Depth of Grout Seal a Type of Grout ❑ Public ❑-Other ❑ Delta f��pprox. Depths ❑ "Ea'stern�" Surface Seal Installed by ❑ Irrigation Pump Ly H. P.1 State Work Done w �'f ids ► Repair Work Done ElType of Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 } Depth Filler Material [Below 50'1 I 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 CDmm'erclal Other r i F Number of livingunits:,' Number of bedrooms I 'Character of ,,soil'to , - -- --�-_. Water table depth depth of -3 feet:--'"'- - 1-'" ""'T"-' " - SEPTIC TAMC ❑ Type/Mfg Capacity NA, No. Compartments . , " Method of Disposal PKG. TREATMENT PLT. - ❑ is Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. &Length of lines Total length/size r FILTER BED ID Distance to nearest: Well Foundation -Property Line - -' SEEPAGE PITS ❑ Depth Size Number - II SUMPS � ❑ Distance to nearest: Well z. Foundation Property Line x DISPOSAL PONDS t { I C l C 0 L�, Thereby certify'that l have prepared this application and that.the work will be done in accordance with San Joaquin county ordinances, state laws, ano Pules and regulations of the San Joaquin Local Health District. r+ Ii I home owner or licensed agent's signature certifies the following: '}'certify -that in the performance of the work for which this permit is issued, I shall not i3rnploy any person in such manner as to become subject to workman s compensation laws of California." Contractors -hiring or sub -contracting signature certifies the following: "l certify that in the performance of the work for which this permit is issued, l shall employ persoins subject to workman's compensa- tion laws of California." The applicant m�callfequired in ctons. Complete drawing on reverse side. Signed X Title: 19 "ollij— Date: Sly --+OR,DEPARTMENT--USE ONLY x �`► Date Area / Application Accepted by I ' ( -Date r'$ Final Inspection by Date Pit or Grout Inspection by -�—� II it . _ 1 nil - T' -gyp .- —I� rt,-x,t -Y( Additional Comments:"h O u ' "r "` '" " - _ q ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca t823-17104 Tracy 835 f Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. rHazelton Ave., P.O. Box + EH 1324 HIM EH 14-28 6 fX 1.2--