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i l APPLICATION FOR PERMIT 411,'- SAID JOAQUI N LOCAL HEALTH DISTRICT ., 1601 E. HAZEL'rOiV AVE., STOCKTOIV, CA _ R. Telephone (209) 466-6781 +< ?rti PERMIT EXPIRES 7 YEAR FROM DATE ISSUED (Complate in Triplicate) Application is hereby made to the Sart Joaquin Local Health District for a permit to construct and/or install the work herein dejerlbed,This sppfiention is made in compliance vtith San Joaquin County Ordinance No.F4,9 for sewage or No.IM 2 for well/pump and the Rubs and Regulations of the Sen Joaquin ' Local Health District. i Z: Job Address1 1 C -j fL L t �L� -LV' 1 �` City ..t.*~?= IMP.le-0-�/F .,_S CPM Owner's Name L de O 6�r,F- Address _ pjgnyy J Contractor L w R L7}��tL� Address_��t/ W � 9X J{D. f _ _ �� _:License fto.. �Q Pttorte tr {v TYYf;OF WELLJPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ''4 1,"� y PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ ?i DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES O1SPO5AL FLD._ PROP. LINE r' FOUNDATION AhVICULTURE WELL OTHER WELL PITS/SUMPS INTENDF,D USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' r C Industrial ```C7 Open Bottom ❑ Manteca Dia. of Well Excavation Via,of Wag Coal g { F;P ❑ Domestic/Private C Gravel Pack ❑Tracy Type of Casing---_ -A, '-A, F C Public Ll Other O Delta Depth of Grout Seal Type of Grout--- 0 g _ Approx. Du th ❑ Eastern Irri etion p Surface Seal Installer!by 1 --� Repe)r Work Dene ❑ Type of Pump _ H.P. State Work Dong ' Well Destruction 0Well Diarrletpr _ Sealing Material flop 50') f- i4 Depth Filler Material leelow 50') l TYPE CF SEPTIC WORK: NEW,INSTALU,TtUN❑ REPAIR/ADDITION fa7�ESTRUCTION a septicsystem permitted If puLlic sewer is - available within 200 feet.) of : Inetauation wilJserve: Resi ace��Commercial— Other h a 1, k _ Number of Ilvirig units: Number of bedrooms __ y Character of soil to a depth of 3 feet:_ I / Water table depth ` SEPTIC TANK 0 Type/M, fg•- Capacity/ No. Compartments ! PKG.TREATMENT PLT.❑lr Method of Di I (�! �, t r DistanF -•-Le to nearest: Well -.Foundation ( `-,_ Property Line ` LEACHING LINE 9—No. & Length of lines Total length/size _ FILTER BEDr ❑ Distance to nearest: Well Foundation�„�— property Lina 4 SEEPAGE PITS ❑ Depth t : Number rz t? SUMPS 0 Distance to nearest: ' Well Foundation _ Property Line DISPOSAL PONDS ❑ -• C7 f l k !herehy certify that I have prepared this application and t'at the wor! will be dane in accordance with San Joaquln county ordinances,state tam,and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's segnaturrl'certifies the following:"I certify that in the performance of the wort for which this permit is issued,t shall not ) t employ any person in such manner as to become subject to workman's compensation laws of California,"Contractor's hiring or subcontracting signature ' c 'flea the following:"I certify that in the performance of tho work for wh)ch this permit is issued,I shall employ persons subject to workmRn's compensa- teen f of California." ' The applets ust calf fo all r ulred rs. ompl�ete drawing on arse sielp. Signed } Title: Date: FOR DEPARTMENT USE ONLY p / ' AppE)cstion Accepted by 2_ Date !grea Pit or Grout inspection by Data Final Inspection by Date--;2-- � Add?tlonal Comments: f 0 Stk a:;&MI ❑Lodi 36$.3621 ❑Manteca 823-7104 ❑Tracy Mr-6385 Applicant-Return all copies to; Environmental Health Permit/Servicas te0t E. Hazafton Ave„ P.O. Box 2009, Stk.,CA 96201 } f.. FEE AMOUNT DUE AMOVN7 REMITTED INFO, H RECEIVED 8Y DATE PERMIT No. - t a£H 1124{REV,1/0 W FH 14-20 O (J ♦ p.J "J`/ _C�`