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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT,/ N.J � Telephone (209) rERMIT EXPIRES 1 YEAR FROM DATE ISSUED UU (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 Local Health District. �y,.,�yL� Job Address ZZ 4 S t rr lr — City 5+D^1J1LL Lot Size PM I Qo3 S0 ISS't5 Rud owner's Name lCja�__ Address �jQ ZoS Phone l<le rc K filer S 2.E� Iti m o�S M (.pm 4b5 V/,, Contractor Address License NoPhone TYPE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X SOIL BOIZIA7iyS DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION /d AGRICULTURE WELLNIA-- OTHER WELL ITT PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 4.1,—Bottom ❑ Manteca Dia. of Well Excavation F/.1 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 1)C1/1G r Specifications �//�� jL, M Public ❑ Other 71 Delta Depth of Grout Seal Type of Gpro�utNCi -&/ryn . I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed h Vh/1Q OYYI Repair Work Done ❑ Type of Pump H.P. State Work one _ 4 Well Destruction ❑ Well Diameter Sealing Material (top 50') I" Depth Filler Material (Below 509 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REP AIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is ( _ available within 200 fee[.) 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 Foundation Property Line LEACHING LINE ❑ No. d Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: 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 District. 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 compens t- tion laws of California." The applicant mus I for all required inspections. Complete drawing on reverse side. Signed N� Title: P'44 4144 to t z r Date: I Z_t t'`1 ti FOR DEPARTMENT USE ONLY Application Accepted by ` t Date / L Area �Lr Pit or Grout Inspection by //�/(' Da e / 3�1g2— Fina/l Inspection by - -` Date Additional Comments: �P � V Applicant- Return all copies to: Environmental Health Permit/Services 1 �. N � Au P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. INFO /yam• CASH2 �.EN 113-24(REV.rix 5) (J 9 9 T3 � �i�-- 9.2-1400y)1 EH 1426