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� K APPLICATION FOR PERMIT wo �035q D SAN JOAQUIN LOCAL HEALTH DISTRICT 445 iA, 5A-g aDAQ0%*1 Telephone (7.09) ¢bQ, • 3 4.7.0 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 describedThis application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address LEUSIR,RWQ 60' AID 150trTotACity 6MCANDIJ Lot Size PM Owner's Name P(AS tv • Address �Q_. , t S'1t�G1'�'�ON I�l q� } Phone .(K. MDRS E HEAD) ` �6i-t��/z o.y Contractor_ Address CA-MT6f'_, 1bG1.3_0ALicense No. on � D 9 TYPE OF WELL/PUPAP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER A ANO W SLI,. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS tJ\ INTENDED USE TYPE OF WELL PROBLEM AREA COhISTRUCTION SPECIFICATIONS �J.industrial 'Open Bottom ❑ Manteca Dia. of Well Excavation_ - 10 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Typu of Casing t� ` t• Specifications' M Public F1 Other Cl Delta Depth of Grout Seal go Type of Grout 4.08CALS010 I I hrk anon JUTApprox. Depth l I Eastern Surface Seal Installed by fatrip>~a B y�e l.t.. Repair Work 06-ne ❑ Type of Pump tACNAE H.P. _ State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 LO Kr; BUMSMZE C.HOK'1'OM 52' TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 :iEPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other _ Number of living units: Number of bedrooms C`:aracter o: soil to a depth of 3 feet: Water table depth SEPTIC: TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size \�? FILTER BED ❑ Distance to nearest: Well Foundation^ Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will he 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 fallowing: "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, I shall employ persons subject to workman's compensa- tion laves of California." The applicant must call for all req;'ed inspections. Complete drawing on reverse side, Signed X � Title: znvr Date: te iZ VADf I.uCG N 1 USE ONLY /f App..cailon Accepted byJ�;.ZF =RTMENT Date ea 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 INFO AMOUNT DUE AMOUNT REMITTED AS RECEIVED BY DATE PERMIT'NO. ..EH13-24 aREV.i I x s I j�WF_qq EH 11-28 v V V l+ 5,17 L S