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gr q_ f�-•. + 'y s`�` �'_,"5 '�T dllf�srl. � i.�I��,} _,_s „,? �tq. i,-;�+. '�. ' ;,�?a ,. .y�., , �...a ri ..f, '� ''4"'fir .X��,,.��hu; .;.r,r ,. ,rb�;:�� a�*�' A APPLICATION FOR PERMIT SJ4NJOAOUIN LOCAL HEALTH DISTRICT. xI 1601 E. HAZELTI ON AVE., STOCKY.ON; CA Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED w g t {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 1 Local Health District. / 4 j Job Address City " Lot Size PM +, Owner's Name: Ad dre / �U r-.�% YjILC �GAPhi r /} I Contractor's Name nse No. Phone' w i TYPE OF WELL/PU NEW WELL ❑ WELL REPLACEMENT El ;DESTRUCTION ❑ . :a PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER LJ DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL t PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial q Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ` Type of Casing Specifications ❑ Public, ❑ Other ❑ Delta Depth of Grout Seal Type of Grout r z ❑ Irrigation _Approxi Depth ❑ Eastern Surface Seal Installed by Repair.Work Done ❑ `.Type of Pump H.P. State Work Done Well Destruction ❑ . tWell Diameter Sealing Material {top 50'1 Depth Filler Material.(Below 50') : TYPEOF SEPTIC WORK: NEW INSTAL ON ❑ REPAIR/ADDITION- DESTRUCTION (No septic system permitted if public sewer is a El within 200 feet.) frr Zinstallation will serve: Aesi ence f' Commercial_ i0ther Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK y ❑ Type/Mfg ' B Capacity - No. Compartments K PKG. TREATMENT PLT. O `— `' Method of Disposal :> - ! Distance to nearest: Well _ ._._ Foundation Property Line LEACHING LINE _ ❑ No. & Length of lines Total length/size FILTER BED ' ❑ Distance to nearest: Well Foundation Property Line . ro ❑ Depth'+ Size mber : - UMPS ElDistanCe10 nearest: Well Foundation� ,. I Property Line DISPOSAL PONDS ❑ v# t .r #� I hereby certify that 1 have'prepared this application and that the work will be done in accordance with.San Joaquin county ordinances, state laws, and t rules and regulations,bf the San Joaquin Local Health District. , Home owner or licensed,agents signature certifies the following: "I certify that in'the performance of the work for,which this permit is issued, I shall not 9 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 iri'the performance of the work for which this permit is issued,I Ghali employ persons subject to workman's compensa. t tion laws of California." t The applicant must call f ll reqri d inspections...0 mplete,drawing on reverse side. . Signed Title: Date: - FOR DEPARTMENT USE ONLY 1zApplication Accepted by i Date �� A4, ' /Pitior Grout Inspection by Date Final Inspection by Date - LL9 - Addditional Comments: 6,❑ 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.- „w - t FEE AMOUNT DUE AMOUNT REMITTED'.' CK RECEIVED BY DATE` PERMIT"NO. + , INFO CA` 4 ks+'EH 13-24 IREV:'101835 EH 1428 _ .