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l _..A6 APPLICATION FOR PERMIT Ufa +tiJ,t A4 N JOAQUIN LOCAL.HEALTH'DISTRICT 1601 E. HAZELTON AVE., STOCICTON, GA w, Telephone 1209) 466-6781 iPERMIT EXPIRES 1'YEAR FROM DATE ISSUED Pr` I �' {Complete in Triplicate) G 4 Application is hereby made to the SanJoaquin 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. i Job Address �ydS z `l�+fes. 'rrc� City C.?/Ml Lot Size PM J 14 l Owner's Name ,!� �,� r�I b Illi Address �M� Phone Contractor c4e' ✓ isit t41Q Address � ,de5A) License No. yy6�7a Phone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ElDESTRUCTION El k PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER XSar i ?!HS s �3) i' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FLO. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS'i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casili ng r � I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (`l Public W Other Cl Delta Depth of Grout Seal 6,1 Type of Grout I I Irrigation 2a-ApproK. Depth t I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done A Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION I ] DESTRUCTION I I INo septic system permitted if public sewers 11 available within 200 feet.l 0 Inst;llation will serve: Residence— Commercial— Other i VIi Nuiber of living units: Number of bedrooms Chacter of soil to a depth of 3 feet: Water table depthn ( SEPI EP iC TANK ❑ Type/Mtg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line a �� 4 r.. LEACHING LINE 0 No. & Length of lines Total length/size F FILTER BED ❑ Distance to nearest: . ell - Foundation Property Line SEEPAGE PITS t 1 Depth + Size Nu her SUMPS LI Distance to ne rest: Well Foundation Property Line �- DISPOSAL PONDS ❑ ' j. - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, statelaws, and CO { rules and regulations of the San Joaquin Local Health District. CS I 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 sub-c6ntracting signature �A 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." '} SAN JOAQUIN LOCAL HEALTH°DES T R!CT The applicant s call for all qu"`d# inspections. Complete drawing on reverse side ENVIRONMFN AL H3 AI=�!-! IV SION AL Signed X M� � ! Title: °r FO SPARTNIENT USE ONLY Application Accepted by Data_L'/r�J� Area f Pit or Grout Inspection by Date Final Inspection by Date _ 1 Additional Comments: F-1 Stk 466-6781 ❑ Lodi 369 3621 ❑ M tete 823 7104 ❑ Tracy 835 5 c o Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 009, Stk., CA 95201 FEE AMOUNT DUE' AMOUNT REMITTED CASH RECEIVED BY DATE PERM&NO. INFO +.EH 13-24(REV.i/m 57 �r .� � � 117q ,I�sc> �, ..- EH 14-211 -