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APPLICATION FOR PERMIT x VAN JOAQUIN LOCAL HEALTH DIS AT — H Telephone (209) 46&&M Lto l 311,0 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. T{� Job Address r'',, ' I �' City { rAC Lot Size " ' � PM Sa V1 Owner's Name tA�'aa-1 P Addre55�00 Cr" �.lN..{4a 1 400�{/'{WI Phone ' 4 — (� 4IT Contractor f ML(501 15kME!1ft Address47 "l5-, San g License No.G57 L�(a 34-7 Phone 4S-0—q 9-7r TYPE OF WELL/PUMP: NEW WELL'o WELL REPLACEMENT ❑ DESTRUCTION ❑ vc4'P6r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ IT 5V( 'F llry `ti-IS 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 15-0—M. Bottom ❑ Manteca Dia. of Well Excavation 2" Dia. of Well Casing „r ❑ Domestic/Private ❑ Gravel Pack _ ❑ Tracy Type of Casing �>4') a� i` Specifications 11 Public ❑ Other WW" ❑ Delta Depth of Grout Seal 5 Type of Grout U-e c,+ t-em c^Y I I Irrigation 0 Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 l REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will carve: Residence_ Commercial_ Other \i _ Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ 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 SEEPAGE PITS I I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 permits 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." The applicaingmuyI cal for all required ins tion$. Complete drawing on reverse side. 1 Signed X . ��t /"d!i/ 1 '� I L ,1s i�. e: �� /tl L� ��`/0-G r Titl L� Date: r-,M ,r FFOOR DEPARTMENT USE ONLY 1 ,-r/1�j - Application Accepted by "`�- 1 \U Date Area C ` ` O I Ph or Grout Inspection byr Date - Final Inspection by Date Additional Comments: .A15o ib✓' '� hy-,sm✓qy._CAt, ( )O Stk 466-Ml ❑ Lodi 369-3621 O Manteca -7104 1 ❑ Tracy 835-M 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 CK RECEIVED BY DATE PERMIT-NO. INFO ��}}},,, CASH wEM I}N(REV.t/x51 `/111 I�✓ (/�/� VV� Ip� EH 1416 'J ✓ IV )