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APPLICATION FOR PERMIT � � SAN JOAQUIN LOCAL HEALTH Dil'CT �p �4k1 1t 1601 E. If AZEL;i�ONj;4'VE., STOCKTS VjCA_; � P. Telephone (209) 466-6781 �¢q� PERMIT EXPIRES 7 YEAR FROM DATE ISS 1%U,, Sp (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 incompliance 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. Job Address o 1 00 City Lot Size PM Owner's Name r Address 6VV Cg?. rQ�t�1�1'LL. ectac 8— Contractor :P—LL NIA23 S �� .� L License NI 2 3 Phone 6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTROOTION ❑ PUMP INSTALLATION ❑ -SYSTEM REPAIR ❑ r ' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE FOUNDATIONAGRICULTURE WELL- OTHER WELL PITS/SUMPS Co INTENDED USE TYPE OF WELL PROBLEM AREA ..CONSTRUCTION SPECIFICATIONS {� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing V ❑ Domestic/Private ❑ Gravel Pack ❑.Tracy Type of Casing Specifications i ('] Public ❑ Oth�ery ;�./ �'Cl Delta Depth of Grout Seat Type of Grout I I Irrigation _Appiox;Depth 1 I stern Surface Seal Installed by _ Repair Work Done *��Type.of Pump � j.H,P. �r State Work done r•\ Well Destructions '❑ -CNeli Oiameter s ;> Sealin.g Mateal [top 501 Depth Filler Nfaterial (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 RFPAIR/ADDITION t I,, DESTRUCTION, I I INo septic system permitted if public sewer is -^ y 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: /` Water table depth SEPTIC TANK ❑ Type/Mfg Capacity,v__..._/ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation ur" Property Line LEACHING LINE ❑ No. & Length of lines Total length/size •; f FILTER BED ❑ Distance to nearest: Well Foundation �� P'Operty Line � I SEEPAGE PITS I I Depth Size Number , SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ %1 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 regulati sof the San Joaquin Local Health DtItrict. Home o r or license ent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not empl any person in such nner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature ca ies the following: "1 c ify that in the ormance a work for which this permit is issued, I shall employ persons subject to workman's compensa- tio laws of California. T applicant ust r all re it i to - ptete)r wing'on reverse sl Sign X Title: - FOR PARTMENT USE ONLY Application Accepted by Date � Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ 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 95201 FEEi INFO AMOUNT DUE AMOUNT REMITTED ASH CK RECEIVED BY DATE PERMIT'NO. � +.EH 3-24 EH 1 (REV.t/H 5) 4-2a u c