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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HTeZe hone 209 466-6781ELTON AVE., ICTOIV, CA RR��V E T Telephone { f D PERMIT EXPIRES 1'YEAR FROM DATE ISSUED AUG 1989 (Complete in Triplicate) p��+' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal�f thyli�brf lh�ieNyri yThis application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the IRRA4P]/EiMLO iblfs'A04 San Joaquin Local Health District. ACES r t Job Address t Q 1R! ��.., City Lot Size * PM Owner's Name SAY / QI1 Address �i -- Phonekdd Contractor "lT Qf Address 4023 jitrt License No.,l;ff-f2l Phone r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �e f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ;1 A __i1C, DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES EAd-*** DISPOSAL FLD.AIA PROP. LINE FOUNDATION +4a�� AGRICULTURE WELL OTHER WELL PITS/SUMPS M q I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing AMW4 Specifications f'l Public ❑ Other F] Delta Depth of Grout Seal Type of Grout�_Cl 11 Irrigation _.-Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work one Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) 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 l Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size f FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS l I DepfR Size _ Number i SUMPS 0"Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ j 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 Di§t6ct. 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 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, l shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all requ ed inspe ions. Complete drawing on reverse side. Signs/X— r Title: /f if Date: V.7 D ENT USE ONLY Application Accepted by C Date a Pit or Grout Inspection by Date 4 Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ odi 369-3621 ❑ Mante a 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO + EH 14.24 1REV. � ' EH•1426 / --