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APPLICATION FOR PERMIT I.We SAN JOAQUIN LOCAL HEALTH DISTRICT Cap 1801 E. HAZELTON AVE., S N, CATelephone (209) 466-6781-6781 V 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. �7 - Job Address �//�1�~�� /�C• O� J,, City 4 Lot Size PM Owner's Name Cl.l. C Address d'9?2!:( Phone fg-f-7 o61l Contractor Address License No. 493 W Phone 2;fC TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ -RUMP INSTALLATION El . SYSTEM REPAIR O _ OTHER 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing - Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _ —Approx. Depth I I Eastern Surface Seal Installed by _ J Repair Work Done ❑ Type of Pump H.P. - State Work Done _ J Well Destruction ❑ Well Diameter Sealing Material (top 501 ' Depth - - --Filler Material (Below 501 j TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ZW DESTRUCTION I I (No septic system permitted if public sewer is av 1 . I m 200 feet.) Installation will serve: Residence_ Commercial_ Other j�G.f'rn (�/6w;& Number of living units: _ Number�of,,bb dr�°ms�� JCharacter of soil to a depth of 3 feet: sYL7A4,� C ,-5- - Water table depth t SEPTIC TANK ❑ Type/Mfg TCapacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line ' r LEACHING LINE No. & Length of lines C/ --' t Total length/size FILTER BED ❑ Distance to nearest: Well�S 1' Foundation Property Line SEEPAGE PITS 1111 Depth A Size -2 Wd- 1 p Number SUMPS lyr Distance to nearest: Well -Foundation�y�. Property Line 3 DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the,wofk wig be done in accordance with San Joaquin county ordinances, state taws, and rules and regulations of the'San Joaquin Local Health Di3trict. Home owner or licensed agent's signature canities 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 for workman's compensation laws of Califdrnia." Contractor's hiring or sub-contracting signature certifies the following: "I cenify 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 applicant must call for all quired inspections. Complete drawing on reverse she: 1 Signed X� x Title: (V ek.)A)CL Date: FOR DEPARTMENT USE ONLY Applica ' n Accepted by Date Area l Z bon by dZ Dat�e .' Li Final Inspection by Date LLO I Additional Comments: i ❑ Stk 466-6781 ❑ tbdi 389-3621----O-Manteca-823-7106—Biracy-83 6385_ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EM 1324IREV.11.51 EH 14-M