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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., ST'OCKTON, CA Telephone (209) 466-6781 ,PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .u•: , (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: 6 �a. . ` -f , P - C Job Address � - City Qin 6�Lot Size • PM . } }} , � �ec3--771 Owner's Name � ` � LO W�•� Address /V /7hone Contractor y ��I� Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑1 DESTRUCTION ❑ PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE " FOUNDATION AGRICU ELL OTHER WELL PITS/SUMPS INTENDED'USE TYPE OF WELL PR AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing { EJ Domestic/Private LJGraVel O Tracy Type of Casing Specifications ❑ Public ,/ ❑ er ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation s r ___,.-.:�4pprox. Depth ❑ Eastern r Surface Seal Installed by Repair Work Done Type of Pump H.P, 1 State Work Done _ -" * - WeA Destructio ❑ Well Diameter " Sealing Material (top 50') i •' b' Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIO DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other v " Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: J Water table depth SEPTIC TANK ElType/Mfg!'( �S Capacity �a No. Compartments PKG. TREATMENT PLT. 1-1I Method of Disposal Distance tri nearest: Well Foundation Property Line .l LEACHING LINE >No. & Length of lines Total length/size ra FILTER BED ❑ Distance toynearest: Well Foundation >IQ Property Line SEEPAGE PITS ❑ Depth Fn Size 10 ?Q0 X/0 Number, * x 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, I shall not f employ any person in such manner as to become subject to workman's compensation laws of Califomia."Contractors hiring or sub-contracting signature J 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 r wired inspections. Complete drawing on reverse side. I Signed X_ Title: ?T"j?• Date: 04 Z-ZS- FOR DEPARTMENT USE ONLY } Application Accepted by C Date �&Z Area U�- Pit or Grout Inspection by 1V 1A Date Final Inspection byDate (�� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835.63M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CK��yy CASH RECEIVED BY DATE PERMIT''NO. + EH 13-24(REV. /a 5) / — V L 33 I 1 '�' -EH 144.28 j ��-111 !�^' � r