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0 J APPLICATION FOR PERMIT '7/ 7k 5 1P ( SAN JOAQUIN LOCAL HEALTH DISTRICT 1'a 1601 E. HAZEL i ON AVE., S70CK70N, CA 1� (. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 T fQ x. elceAR'At- City Lot Size PM Owner's Name &444nA, pa- Address 1,A d A r Ph.,33!V 0—?3 Contractor a J Address[a 416 .Agem-_0_ License N .r,.3 72 Phon'6� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER ❑ 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 ❑-- Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing lt�'Domestic/Private ❑ Gravel Pack C1 Tracy Type of Casing Specifications Fl Public D Other Cl Delta Depth of Grout Seal Type of Grout _ I I Irrigation ---Approx. De h l I Eastern Srlrface Seal Installed by _ 00 Repair Work Done ff Type of Pump H.P. Jy�lr State Work Done 0-9, Weil Destruction ❑ Well Diameter Sealing Material (top 50'1 - Depth Filler Material Welow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) - Installation will serve: Residence_ Commercial____ Other b Number of living units: �Nu b r_of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Me't,�0 of Disposal tMin Distance to nearest: Well Foundation Prope L'Ve ; Pl i LEACHING LINE ❑ No. & Length of lines Total length/Ai`z>3 f "4 FILTER BED ❑ Distance to nearest: Well Foundation y er eine PI lo, JJ Ql1fN C r Ty SEEPAGE PITS l I Depth SizeIWJMr1tSi W4&rXAL H SERV) Ec, SUMPS L1 Distance to nearest: Well Foundation Property LineALTH DjVfsl{} DISPOSAL PONDS ❑ 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: - --- 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, t 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 t call for all re .red inspections. Complete drawing on reverse side. (f Q Signed X le: _—,/`�7� -- Date: O l FOR DEPARTMENT USE ONLY Application Accepted by Date � ea Pit or Grout Inspection by Date Final Inspection by Dat�1' 2_ Additional Comments: P w`� ✓ ol/�� !��✓� /J' _ ^ ❑ Stk 466-6781 ❑ Lodi 369.3621 El Manteca 823-7104 ❑ Tracy 835-6355 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. � +.pH13-241pEV.t/H51 rid © e ZZ J- 9�J� EH 114.26