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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELT ne AVE., 6-6781 ON, CA �(lf. ,T Telephone (los) ass-s�gi ,VQa jl�l.�]�j� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j� (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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 44—/3—/27 �^7I� � Job Address[_.4l (OAF)COD `` Ci, Lot Size�X��n/ PM Owner's NameF �i�CKZ� Address Phone Contractor .ZlV Address_ WAY License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTAN€E 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 ❑ Industrial ❑ Open Bottom ff Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Dornestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications - ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout AJ ❑ Irrigation --Approx. Depth . ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth 9 Filler Material (Below 501 TY*F SEPTIC WORK: NEW INSTALLAI*N ❑ REPAIR/ADDITION)q DESTRUCTION ❑ (No septic system permitted if public sewer is v available within 200 feet.) -P (t Installation will serve: R i once _ CommercialO her Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet.15M 2V C _ _� Water table depth 5 C SEPTIC TANK gUSr❑ Type/Mfg Capacity No. Compartments Q PKG. TREATMENT PLT. ❑ Method of Disposal C Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED X Distance to nearest: Well ,E< Foundation Property Line �R�x /5'X 30 s►>�rJy -ycS�sF SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 .. 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 permit 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: "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." The applicant must call for all require ctions. Comple a drawing on reverse side. yI Signed Title: +vim-�/�1 + Date: (lr�� rt,, DEPARTMENT USE ONLY Application Accepted by �An� •^ •�i� vnC Data U Area ,/ �/ Pit or Grout Inspection by Date Final Inspection by Date A Additional Comments: ❑ Stk 4666781 ❑ Lodi 365-3621 ❑ Manteca 823-7104 ❑ Tracy 835541385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 FEE INAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO, EH 2.IREV ,,e51 n. ©a -/a �'�' ;Z�6 W EH 1418