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i n APP IC ANON FOR PERS .,Js T SAN aOAQUIN LOCAL HEALT'= DISTRICT 1601 E. PIAZE! TON AVE_ STOCKTOiN, CIA Telephone (209) 466-6781 PERMIT EXPIRES , YEAR FROM DATE ISSUED (Complete in T ripkate) FApplication is heteby made to the San Joaquin Local Health District for a permit to construct and/or install the wark herein described. This application is [ made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1,762 fcr well/Pump and the Rules and Regulations of the San Joaquin 'I Local Health District. 44 Joh Address L �7 f ref Cit~ Lot Size " PMY F f v Owner's Name =1f � ''� r if Address Phone j _' r ' i. -tom' re � r f_ ' ns No. Phone Contractor — 6 TYPE OF WELL/P MP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLAT?ON ❑ SYSTEM REPAIR. C7 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL ILD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1NTLNDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation ..Approx. Depth t I Eastern Surface Seal Installed by F, Repair Work Done ❑ Type of Pump H.P. State Work Done _ { Well Destruction E] Well Diameter Seahng Material (top 50.) r Depth Filler Material (Selovy-50') TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPASRIADDITION IV DESTRUCTION I I lNo septic system permitted if public sewer is IIID ; available within 200 feet.) Installation will serve: Residence Commercial J Other j Number of living units: _ Number of bedrooms p"_- I Character of soil to a depth of 3 feet: Water table depth �r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: k-4-lull Foundation Property Line t LEACHING LINE LI No. & Length of lines Total length/size Yo FILTER BED ❑ Distance to nearest: Well f. Foundation =t Property Property Line t..: SEEF-AG E,.P I T S I I Depth - e—! Number I SUMPS Ll Distance to nearest: Well Foundation - ' Property Line ; DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work vvili he done in accordance with San Joaquin county ordinances, state laws, and rutes and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the toliowing: "I certify that in the performance of the work for which this permit is issued, I shall not d employ any person-in such manner as to become subject to workman's compensation laws of California." Contractor's hihng'of sub-contracting signature t certifies the following: "I certify that in the performance of the work for which this permit is issued, f shall employ persons subject to workman's compensa- tion laws of California." The applicant mu 5t c afi for all required i cations. Complat a€awing on averse side. Signed X ff r "� T+tie: /'Z' mm_ Date: l FGR DEPARTMENT USE ONLY ,+ ! Applic tion Accepted by _ a" ' �r� ' -� / Date E Area Grout 1n ection by ' �/ Dc!,Ct Final Inspection by�1 �°�+ =LeDate Additional Comments: 1-1Stk 466-67$1 C1Lodi 369-3621 Ll Niantoca 823-71C14, ❑ Tracy 835-6385 I ry F! , ? Applicant - Return ail copies to: Environmentat Health Permit/'Services 9601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t ; 1 IFEO EE AMOUNT DUE I AMO) "1T REMITTED`- CASH RECEIVED 9Y DATE PER cH 1A?c i � -�_..�_4.-- t — :m :,�' '^•_•x-._" 1 I j j• };�'�i (.�. J ._