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it it �! APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �0 3601 E. HAZE i ON AVE., S70CKTON, CA Telephone (209) 466-6781 �f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he;eby 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 welUpump and the Rules and Regulations of the San Joaquin Local"Health District. f '1 Joh Address +� d 7 /� Cit at Size PM Owner's Name /] /� L Address Phone 'Contractor J�/.'C.i✓SIJ[ Address License No, Phone 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 ti El Open Bottom ❑ Manteca Dia. of Well Excavation = Dia. of Well Casirig ' ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy' - Type of Casing Specifications i 7 Public Ll Other F1 Delta Depth of Grout Seal Type of Grout _ I I Irrigation _ -Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done 0 Well Destruction 0 Well Diameter Sealing Material (top 501 .F Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l'l- REPAIRJADDITION l I DESTRUCTION (No septic system permitted if public sewer is wt available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms >r Character of soil to a depth of 3 feet: (w Water table depth SEPTIC TANK ❑ Type/Mfg Capadit�' No. Compartments PKG. TREATMENT PLT. O _ Method of Disposal w ', uat Distance to nearest: Well Foundation o..� Property Line LEACHING LINE ❑ No. &Len th of lines JJ VL 9 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property tine SEEPAGE PITS I I Depth Size r'^ Number SUMPS ❑ Distance to nearest: Well foundation Property Line 4, DISPOSAL PONDS ❑ 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. �'; N Home owner or licensed agent's signature certifies the following:."I certify that in the.0erformance of the work for which this permit is issued, 1 shall not. employ any person in such mariner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: '9 certify that in the performance of the work for which this permii" issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for II required inspections. Complete drawing on reverse side. Signed X < Title:. _ $ • Date: �� '•�� / R D RTMENT USE ONLY Application Accepted by 0 iL x&AQL NA&n .Date I Q 00b7__- Area Pit or Grout Inspection by Il':! r Date Final Inspection by Date��© Additional Comments: ❑ Stk 466-6781 El Lodi),369-3621 © Manteca 823-7104 ❑ Tracy 635-6385 j Applicant - Return all copies tot Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE �-AMOUNT�REMIT_TED.:-' --RECEIVED BYE- - DATE - PERMIT HO.� iFEE CASH + EH1 3-24 JAEV.I i n 51 �' EH 1426 J Y � �. .J� / �� O r l ✓a