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�V)i lIre APPLICATION FOR PERMIT—,__�� n� ' � IrAN JOAQUIN LOCAL HEALTH D�tAl([)# STr�* Old 1377!2 1601 E. HAZELTON AVE., STOCKT Telephone 12091 466-6781 PERMIT EXPIRES i YEAR FROM D D (Complete in Triplicate) -----------0 Application is hereby made to the San Joaquin Local Health District for a permit to constructInAs Ia licatio is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for we pu in Local Health District. Job Address S EAS-r_LC D= AQS City L0 D= Lot Size PM Owner's Namef Address (P24AHAW t ILLI.�'tV`�i�CPQ hon 3(d8"� —* 274.1 [kM2 , b,McEGVf�G4 q!R35_1opo 53 � Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �'SctLltJh DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of y9rl Excavation Dia. of Well Casing IA C Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing�AQCA-511."_y Specifications 17 PublicOther n Delta Depth of Grout Seat _�,r Type of Grout 3�►l�TV I I Irrigation Approx. Depth 1 1 Eastern Surface Seal installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done, Well Destruction ❑ Well Diameter Seaiing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_- Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity N Compartments PKG. TREATMENT PLT. ❑ I1�11 AAE^T1 Distance to nearest: Well Foundation Prape 1 � LEACHING LINE ❑ No. & Length of lines Total length/ e FILTER BED ❑ Distance to nearest: Well Foundation p 6�JWUIN COLIN Y VOWP'nF'�-P I- HEAL,rH,,5EpVICES SEEPAGE PITS I I Depth Size Number UlftlON SUMPS Ll 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 laws, and rubs and regulations of the San Joaquin Local Health D13trict. Home owner or licensed agent's signature cartifes the following, "I certify that in the perfomtanee of the work for which this permit is issued. I shad not employ any person in such manner as to become subject to workman's compensation laws of California."Contractees 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 laws of CaWomia." Ths applica�ntmu AS��ns. Complete drawing on nvarsa side. Signed X ' "' '` Title: r tr� Date: FOR DEPARTMENT USE ONLY Application Accepted by 5Ao� Date /�J Area Ph or Grout Inspection by Date F e 1J 1 I by Date Additional Comments: 1 3 5-5 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca ffi3-7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Setvicm 1601 E. Hazelton Ave., P.O. Bax 2D09, Stk., CA 95291 c D� IFEEO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ..EM14-2e1AlV.tixer 0 /� O /� oO /37/ 1�2e [�7 1 / / f�J s