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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZEL T ON AVE., STOUTON, CA F Telephone 12091 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED C (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. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1$_62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r Job Address-2 C3 a Lea,4,�`P-i' City Lot Size PM/ R,4NTA-1�ff�-e b 0 A A—Z /r ddress rot / /(a 70 Owner's Name __ � �� /�';�" Phone nf� ! I Contractor 1�o Address License Nn! Phone TYPE OF WELL/PUMP: NEW WELL.B' WELL REP MI=NT ❑ DESTRUCTION ❑ PUMP INSTALLATION W�' SYSTEM R AIR ❑ OTHER ❑ p p DISTANCE TO NEAREST: SEPTIC TANK /;fb `0 SEWER LINES- f f DISPOSAL FLD.��, d r PROP- LINE ryv,• FOUNDATION AGRICULTURE WELL ! OTHER WELL PITS/SUMPS/V_d_*C i I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFiCAT10N - © Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatio � Dia. of Well Casing Cry domestic/Private DrGravell Pack C+3'Tracy Type at�Casing Specifications I M Public Cl Other 17 Delta Depth of Grout Seal Type of Grout i I Irrigation __Approx, Rept l I I Eastern Surlac Seal Installed by Repair Work Done 9" Type of Pump H.P, State Work Done I Well Destruction El Well Diameter Sealing Material (top 501 ! Depth Filler Material 4Aelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1, DESTRUCTION I I (No septic system permitted if public sewer is I available within 200 feet-) Installation will serve: Residence— Commercial_ -Other ! Number of living units: Number of bedrooms R Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ 'Type/Mfg - Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method hof Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of tines Total length/size FILTER-BED ❑ Distance tonearest: -Well Foundation Property Line! SEEPAGE PITS ��I I "Depth Size Number SUMPS Ll Distance to nearest: Well Foundation t Property Line t DISPOSAL PONDS ❑ r ;' : r I hereby certify that I have prepared thisapplication 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.tollovving: "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, 1 shall employ persons subject to workman's compensa- tion laws of California." i The applicant u t call for all re, 'red inspect nsJtComplete}dQrawing on reverse side. �j�- ('�' } Signed X _`�V_ z�C� kz itle: f � s bate: ` J V / FOCDEPARTMENT USE ONLY Application Accepted by Date Area �— y / Pit or Grout Inspection by 1 Z ��Final Inspection by Date/% a Additional Comments: 0 ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicapt Ret pies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009; Stk., CA 95201 FEE CK,4 INFO AMOUNT DUE AMOUNT REMITTED CASH - RECEIVED BY DATE PERMIT 0. + EH 13-24 IREV. /n 51jQs4 EH 14-28 - ,