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.R _ APPLICATION FOR PERMIT - +- SAN JOAQUIN,LOCAL HEALTH DISTRICT , 1601 E. HAZEL.TON"AVE.S r �III�TCftWW_PM1CH$MLTH j. Telephone (209) 466-67dMRONMENTAM IMUR DMSIONRV1 PERMIT EXPIRES 1'YEAR FROM D (Complete in Triplicate) L PERMIT 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 t 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. q Job Address _ .,�� IlfA►a l L. City-t-.n ca s Loi Size IPM Owner's Name L � M'�CQv'_ "rvtir _ Address - Phan = w esT HA MAT �ow� a C A Contract Address 33 "� P. "J'K 0vc'551 q19 Q f 6 63S7� 6 ° en a o.-" Phone TYPE OF WELL/PUMP: NE ELL ;K ' ` ` WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑ •,,O��JHER S' . wog�/I� Wc f'S DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD."Nl! PROP_ LINE FOUNDATION AGRICULTURE WELL Nlhl OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL J. PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial © Open Bottom 0 Manteca Dia. of Well Excavation .i. Dia. of Well Casing Domestic ISO 9 Gravel.Pack_ ❑ Tracy Type of Casing—sclaa D A.PUC Specifications M Public Cl Other K Delta .. Depth of Grout Seal Q-Q Type of GroutMr+ r�y y I I Irrigation 'Cpprox. Depth I i Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump N/A H.P. State Work Da e el estruction 9 Well Diameter " Seating Material Itop 5171 ��n� Depth .O Filler Material (Below 50'1 . NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION l I:1No septic system permitted if public sewer is available within 200 feet.) .. Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms i, Character of soil to a depth of 3 feet: r ' Water table depth _ SEPTIC TANK ❑ Type/Mfg rtments �PKG:"TREATMENT,PLT,.❑ "* tfl�sposal ' V r.W.r ♦ 5k.`,. �• �`_•^"^`«ate-.3..E3:. r t� Distarice to nearest: Well AIMS TMaIz a= RWJ)WfWS LEACHING LINE t.❑ )No. & Length of lines Total length/size FILTER'BED ❑ Distance to nearest: Well Foundation Property Line F, SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required 'nspections. Complete drawing o reverse side" + Signed X Title: Pr 'QC F. EPAR USE ONL Application Accepted byk - /,-7- x DatesArea", 33- k;t Pit or Grout Inspection by Date ` �/� Final Inspection by Date Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 s Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 / i FEE s ' Y INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EK 13.24(REV.1/"sl