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i APPLICATION FOR'-PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE. STO � I GKTON, CA ' Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED APR 09 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hiei�u I HIA, made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and i 1 anon is Local Health District. I / an Joaquin Job Address �• 1 Cit �Oh 3/DGk- y � Lot Size PM Owner's Name `qA �104ulh COU Y7 Address W-41-36 7 7 Phone / �11"�PXrAllf r!a►7{]9h 6330 $rr me R`I Contractor Address GYb CA License No. PhonB ��`��99 TYPE OF WELL/PUMP: NEW WELL !.{ WF9 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1` L DISTANCE TO NEAREST: SEPTIC TANK&wivlil— SEWER LINES d9h'o`WA DISPOSAL FL)�D/4( Coven PROP. LINE J�1111 01941 FOUNDATION AGRICULTURE WFLLIU_rJn+to-6 OTHER WELLu#+A►fLwr1 PITS/SUMPS 1.k*✓n INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel yPack ❑ Tracy Type of Casing 0 p��_ Specifications ��// 1 f'7 Public Ot er�011T}W^♦Y14 ❑ Delta Depth of Grout Seal ^' t7 Type of Grout � t1 I Irrigation 4W.Approx.{Depth(! f I Eastern Surface Seal Installed by Repair Work Done ❑ Type of PumpI H.P. State Work Done r Well Destruction ❑ Well Diameter � Sealing Materia! (top 50'I �F. Depth O rio Filler Material (Below 50') M n TYPE'OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is V' . Installation will serve: Residence�l Commercial____ Other available within 200 feet.) Number of living units: Number of bedrooms - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments '�'PKG. TREATMENT PLT. ❑ Method of Disposal Distance to I nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth ) Size Number SUMPS ❑ Distance tornearest: Well Foundation Property Line 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 Di§trict. 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, I shall employ persons subject to workman's compensa- tion laws of California." f The applicanj call for all regaii Ctio S. Complete drawing on reverse side. r C � R Signed X Title: t�GlilYl►C! Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area j Pit or Grout Inspection by Date Final Inspection by -6 Additional 1 Date �7 1 r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ 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 FEE r INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. a,EH 132 (ItEV.t H5) 1[[' r C) I � ' i�T—� n (' f G/ ,�y EH 14-28 fJ- \ r� I l 1..� L4 �� '-i. f !! ,079 4