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APPLICATION FOR.PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKT_ON, CA Telephone (209) 466-.6781 - ♦n a ..r ,. ..__ .. .. w t.,.,, art .!��r,r. ,) +�,��• �. ^.. ., PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED. _ n' ,> •�' . ;��a :art` >� '"►• - I" (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. TNs•epplication is made in compliance with San Joaquin County Ordinance No,549 for sewage or No. 1862 for well/pump and•the Rules and Regulatiolrs of the San Joaquin Locale Health District. 11.'n �. i'it?^ �nz m ,nTL',. tPb1:1-„'.`.•'k. G 't.•.. �C �' r+' h"" 'r '� � r• � lr� i r- r ter:' � `` Q AA'' -j�`;��I��,�,�;��`� ... Ird) GC ). t:.' . t ;t•7 alrr S 4� Job Address __i `r�O ly• `Jl. .il _.Ci -.Lot Size �� PM n { - - Owner's Name Qd[� _ (ddress t• d. t.)O?C Sot _ J Phone Contractor's Na _l License No. v� Sb� -- Phone 3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT k'7 DESTRUCTION ❑ t r —PUMPANSTACLATION_U —SYSTEM'REPAIR —OTHER-f='•-----+ DISTANCE TO NEAREST: SEPTIC TANK SEVJER LINES DISPOSAL FLD._— PROP. LINE. FOUNDATION,_-_ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C Industrial ❑ Open Bottom ❑ Manteca ,Dia. of Well Excavation___ Dia. of Well Casing ❑ Domestic/Private C Gravel Pack ❑ Tracy Type of Casing. Specifications L) Public = Other s:.'I0 Delta 1t Depth of Grout Seal fc r. 6 Type of Grout Irrigation ---Approx. Depth U'East m� 4j y�$urface Seal Installed by _ .1 Repair Work Done C Type of Pump / H.P. _ State WorkDone Well Destruction C Well Diameter Sealing Material (top 50') _ ___ V Depth " �` Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION E DESTRUCTION U (No septic system permitted if public sewer is L �� _ ` available within 200 feet.) Installation will serve: Residence -" Commercial_ Other' Number of living units: r Number of:bedrooms Character of soil to a depth,of 3 feet:. _ _ _ � -y` _" _ — Water table depth I A_ SEPTIC TANK LTA Type/Mfg r -C �,'� 'Capacity Ia00 No. Compartments _A_.---- iA PKG. TREATMENT PLT. C / 3 F i ��J-: I Method of Disposal r Four-rda�y Property Line P y ' Distance'to nearest:* Well 1 0� � • �� ]r - LEACHING LINE CNo & Leing fh of lines ?1-��y0 r•.t\ rTotal ier�lgth/sae o�PC Y191 j G7 FILTER BED � Cl"`Distance.to'nearest: Well .1.QQ'4 Foundation Property Line SEEPAGE PITS 11 :e -j. �Sk�' Size Number .�. rte• tr`7 \ 1 —T — SUMPS U Distance-to nearest:—Well 1 -foundation %0 Property Lirie IS- DISPOSAL PONDS ❑ ti/ r, w' If ` �`• I hereby certify that I have prepared this,application and that the work will be done in accordance,with Sari Joaquin county ordiriances„state Land rules and regulations of the San Joaquin Local Health District. y'`✓` Home owner or licensed agent's signature certifies the following: "I eeftify that in the performance of;the-yvork for which this permit is`issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California. Cciiht6ctoris hiring or sub-contracting signature certifies the following: "I certify that In the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California.” r The applicant must call for#1 required inspections.,,Gomplete.drawing-on"Feverse side. l 'i I �I I �. P, S � . SS Signed X_ Title: Date: - _J r - If !! FOR DEPARTMENTUSEONLY ZZ ¢¢ Application Accepted by rr ' Date Area y /d at Pit or Grout Inspection by Date Final Inspection b Additional Comments". — ❑ Stk 466 6781'} J Lodi 368.3621 ❑ Manteca 823-7104 ' Ib Tracy"836-G38S - 1 Applicant- Return-all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FtEEAMOUNT DUE' AMOUNT REMITTED _-,-CK 79E'dtiVt) BY— DATE PEAmrr', O. INFO CASH y Ja Wit? + EH 13.24(REV.10/831 — r` 14-25J -� �� EH 1t- �0 �cS Ig.—_ -�-iy !