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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E, HAZEL T ON AVE., STC TON, CAPA Y M E N ,, I RECEIVED Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JUN (Complete in Triplicate) �f�/ [�nr�� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal!thl bdt5flt'A1ENTA6WX,rTjj}is application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and thu �� atiens of t'he San Joaquin Local Health District. Job Address 27 `` CJ @c� l�� J_ !/{J 71� City �� Lat Sizer' KVV PM Owner's Name Address l� Phone L, A,_ CrL Cwx s1-c757c Contractor Address22BI License No.1@ –('1&4 TYPE OF WELL/PUMP: NEW WELL B' WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 63.Ar SEWER LINES }1XD DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rt ❑ Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 a" Dia. of Well Casing _— ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f1 Public 1-1 Othef ❑ Delta Depth of Grout Seal Type of Grout ,"+c1�12mFDrpr I I Irrigation .-Approx. Depth I ) Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump er H.P. Al14 _ State Work Done �I Wel! Destruction ❑ Well Diameter Sealing Material Itop 501 S 01 Depth ' Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I I DESTRUCTION l 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: S,Nom A C\." Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, O Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. 6 Length of lines N Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number ply SUMPS ❑ Distance to nearest: Well Foundation ._ Property Line DISPOSAL PONDS ❑ J 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 rules and regulations of the San Joaquin Local Health Di§trict. Home owner or licensed agent's signature certifies 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 to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: <_.Q lNkX.r Date: �� 6 1 FSR USE ONLY �j'�? C� ' Application Accepted by Date < `Area Pit or Grout Inspection by Date Final Inspection by Date Additional Commt9nts ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk-, CA 55201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVE BY DATE PERMIT NO. , ♦.EHt3-241REV.tiH5] 3S� V� /� ( 0 vJ�"/��/y� V EH 14-28