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y J T APPLICATION-FOR PERMIT . �t� V'gr' SAN JOAQUIN-LOCAL HEALTH DISTRICT 1601 E..HAZEL I ON AVE., STOCKTOW CAR AUG Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED ENYrkU�;t,v rR' 4 PERMr7jSERvey CTT f (Complete in Triplicate) � C - Application is hereby made to the San Joaquin Local Health District fora 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. r �} / +r Job Address _� � � � ff O i9 r �(, D � I. — City Lot Size PM Owner's Name ZV N / A/0 Address N d A !a Phone 6 d ! antractor x 4 License No. / Phone 3/- A�i a TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ! PUMP INSTALLATIO L SYSTEM REPAIR ❑ OTHER Cl DISTANCE TO NEAREST: SEPTIC TANK ! f SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIONAGRICULTUREWELL: OTHER-WELL , -PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial k Open Bottom ❑ Manteca Dia. of Well ExcavationI r Dia. of Well Casing 4 .Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f ❑ Public �❑ Other C] Delta Depth of Grout Seal Type of Grout ❑ Irrigation —:Approx. Depth ❑ Eastern S rface Seal Installed by Repair Work Done.-❑ Type of Pump H.P. I a State Work Done p I-q dr 6��b -X-/.ST/+G C Well Destruction ❑ 'Well Diameter Sealing Material (top 501) IY Depth Filler Material (Below 50') TYPE OF SEPTIC WORK:, NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available.within 200 feet.) 1 Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to-`a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT-PLT. ❑ Method of`Disposal { Distance to nearest: Well -- Property Line 1 LEACHING LINE ❑ No. & Length of lines tTotal;length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size T'Number SUMPS C. Distance-to-nearest: ' Well Foundation "-= "property l ine_ = ` 10 DISPOSAL DISPOSAL PONDS El { i 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 tha-San Joaquin Local Health Horne Distric """"""!' i �� r -• -- - 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 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 s certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ parsons subject to workman's compensa- ; tion laws of Cali nia." , The applicant t calf fo all re 're inspections. C mplete drawing on r rse side. �^ p `- 4 C Signed. Title: �O v 6�TQ Q��/ Date: FOR DEPARTMENT USE ONLY / 6 Application Accepted by Date Area Pit or Grout Inspection by Date Final Ins r pection by Date Additional Comments: i ❑ Stk 466-6781 ❑ 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 �J FEE A INFO MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. CASH + EH 13-24 4REV.1/as) EH 14.28 ��• �� / Q i Q O /