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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT +cltt F uA��'TON�`/-. crnrlrrnnl l'A RE YMEN7. Telephone (209) 466-6781 CE1Vt:p PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` NOV V 28 19y`' (Complete in Triplicate) & Application n hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work V VlR T s application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and eonshe San Joaquin Local Health District. Job Address 4414 Nod-L, Pe-smI N(1 4"E'. + city `'I C)cvf o Lot Size PM Ownor s Nam o r✓ CCf1 r�t (A_ Address l)oo e 1 t t� S I Q F 1 , �O W J 1123 Pn«ta(113 6s 6—77 1676 RISOON ROM License No. y q Phone Ik 6 Contractor rnarnon,_C_g46.18 Address TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ . PUMP INSTALLATION ❑ SYSTEM1❑ OTHER ❑ ^ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Z 5 ��•�" DISPOSAL FUD.�� 7* PROP. LINE 10 FOUNDATION AGRICULTURE WELL OTHER WELD PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ID•�'-� r rt• Dia. of Well Casing /N ❑ Domestic/Private OGravel Pack ❑ Tracy Type of Casing— Specifications S(ah t1 Public ❑rother ❑ Delta Depth of Grout Seal l✓ Type of Grout C61Y ErJ1 2 von,,dercm NOA1t iOJCI mr,-U-Upprox. Depth Tyr Eastern Surface Seal Installed by FU ''u l uG u�L X 21 L7.1 Iva Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50.1 Depth Filler Material (Below 50.1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 I DESTRUCTION I 1 tNo 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 No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: - Well Foundation Property Line SEEPAGE PITS 1 1 Depth Size Number SUMPS ❑ Distance to nearest: Weil Foundation Property Line DISPOSAL PONDS ❑ 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 rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this perrrut is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:'9 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." The applicant t all for all I spections. Complete drawing on r rse side. Signed Title: //S�G �� Date: D FOR DEPARTMENT USE ONLY Application Accepted by //// Date /,/ Area Pit or Grout Inspection by v""'Y� Date 7 i%/^`9 Final Inspection by /�T( "`- — Data 2 / Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7100 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96MI FEE AMOUNT DUE AMOUNT REMITTED- CASH RECEIVED BY OAT E PERMIT NO. INFO ✓/� S EH 13-241HEV. /x 5) ✓ � Chi °`` •LC. �bV165� EH 425 O'J Ej