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Prrrs , X10-01 .03 APPLICATION FOR PERMIT N JOAQUIN LOCAL HEALTH DISTR�T Telephone (209) 469'9991 tfl/11 3W �1 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. - Job Address2105 Er yI--k 2Lf City raC Lot Size PM U d D/� Scan rb"Pi Owner's Name`�`+ "'� Address�co C/ONi w•Tal# 4190 r Phone 1,1 1�z� Sarnt�a*Vfp .I,, Otto) Contractor t've� " "^��1� Address 2?✓ 'l-' License No C51 SS4q7i Phone "727 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ L A --♦_LS PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 10 Vx clelrrmlra N usa FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 2- 0 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing 6G+� '�O PVG Specifications - 7 Public 'RS Other Marl Ablnj n Delta Depth of Grout Seal " Type of Grout 1 I Irrigation 'tP—_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 I1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Or _ 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: ell 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 ❑ 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 taws, and rules and regulations of the San Joaquin Local Health D13trict. Home owner or licensed agent's signature certTes 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 taws of California:' The applicant call for all required i spactions. Complete drawing on/r a�rses/Iqe.�_ / Signed �� Title: X� �1.T �_40k Date: VEFOR DEPARTMENT USE ONLY Cz I -Application Accepted by Date /y Area �N L• r Pit or Grout Inspection by Date Final Inspection by Date C�— Additional Comments: ( -❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M _)Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE gMOUNT DUE AMOUNT flEMITTED CK ED BY DATE PERMIT'NO. INFO CASH s.EH 13-24 IRM trxel 111 &f,,0 &?.00 EH 1410