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{1: -4, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HE iLTH DISTRICT f [. r 1601 E. HAZELTON AVE., STEI(CKTON, CA Telephone (209) 466-6761 x .,+ J PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -(Complete.in,Triplicate) AApplication 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... r k, w cx f' 4 Job Address `� �o �_ 6� Ciryf��— Lot Size _ PM —_ Owner's Name _ —LJ I� �_� Address .�f � �4e� Phone License No. -Phone yam_ 6 Contractor_- _ _ --Address- TYPE -AddressTYPE OF WELL/PUMP: 'NEW WELL C WELL REPLACEMENT ❑ DESTRUCTION { PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER U + +I 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 .'* Open Bottom ❑ Manteca Dia. of Well Excavation_. Dia. of Well Casing U industrial � Opeo„ '— Type of Casing_ Specifications ❑ Domestic/Private 0 Gravel Pack ❑ Tracy II CJ Public -- Other (]'Detta Depth of Grout Seal Type of Grout 1 i L] Irrigation —Approx. Depth O.J] Eastern' t° 'Surface.Seal Installed by + •c -/ H.P. 1 '+ State Work Done_ Repair Work Done L. Type of Pdmp Well Destruction U Well Diameter SealA Material ltop 50'I - - Depth ! j Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION (= REPAIRIADDITION ❑ DESTRUCTION F (No septic system permitted it public sewer is / available within 200 feet.I �V i ✓ 1' a Installation will serve: Residence— Commer"+a1 Othelft� — 1 Number of living units: f. Number of bedrooms - 3 Character of sail to a depth of 3 feet: __��-�fr- - Water table depth SEPTIC TANK L'Type/Mfg -s T` Cape No. Compartments - N,, !+ Method of Disposal PKG. TREATMENT PLT.❑ 1 % I/u r's: l � s_� --t -.Foundation _ Property L Distance to nearest:n Well � _. Line--/-0 — Distance Zy_ No'& Len Length of f+nes� =�,sa '"" ^ - Total length/size_. - - LEACHING LINE 9 ! �; FILTER BED ❑ Distance to nearest: Well /nom Y- FoundationTr?a — Property Line- FILTER ine . ,_Si2e _ SEEPAGE PITS < Depith Number_ ci / / Foundation /moi— Property Line SUMPS ! ❑ Distance to nearest: Well _ L9Q__— I �r DISPOSAL PONDS ❑ 9• -i 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 District:. i l Homeowner or licensed agerrt's signature certifies the folfowin13: "I certify that in the performance of the work for which this permit is issued, I shall not mpensation laws of California."Contractor's hiring or sub contracting signature employ any person in such manna}as.to become subject to workman's co fmortifies the foYowing: "I certify thitt in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tign laws of California.' } The applicant m II for I require inspections. Complete drawing on reverse side. t __�-"` Date �� '. __ _ - _ Signed X - Title: f 1 `~ FOR DEPARTMENT USE ONLY \0\ , r ( �'_~ _ V u. Date_��- \�' — Area -� Application Accepted by n'~"" S — ,� � T Date p Final Inspection by - Data Pit r rout inspection by Additional Comments: n Stk 466-6761 LJ Lodi 369-3621 ❑ Manteca 8223-7104t U Tracy 83`x8385 Applicant - Return all copies to: Environmental Health Permit Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMO DUE AMOUNT REMITTED 0 SH RECEIVED BY GATE PERMIT N0, INFO S~G� S�tr l9 �S`�`�z «EH 13-241PEV-1 t EH 14-26