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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH 'DISTRICT 1601 E. HAZEL ION AVE.; MCKTON, CA Telephone (209)'466-6781 ' PERMIT EXPIRES'? YEAR FROM DATE ISSUED ➢E(Complete,:in,Triplicate) J Cl99SVix3 App 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 • No.549 for sewage or No. 1862 for well/ and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance Local Health District. fti 6 �,-ta err PM 6 City Lot Size Job Address /1k Phone- Owner's Name _ - n - Address fiL�.Gr-�r� 5: �' License No.�✓? --Phone b Contractor �._�v Address TYPE OF WELL/PUMP: --``NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER LJ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL ^PITS/SUMPS INTENDED USE TYPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ^ps_" ❑ Open Bottom 5—ma nteca Dia. of Well Excavation Dia. of Well Casing ❑ Industrial ., Type of Casing Specifications El Domestic/Private ❑ Gravel Pack El Tracy g T e of Grout ❑ Other ❑ Delta Depth'of Grout Seat YP L3 Public 4 { " ❑ Irrigation ---Approx. Depth 1,:❑ Eastern' , 'Surface Seal Installed by x H.P. { State,Work Done Repair Work Done ❑ Type of Pump r j r in Sealing Material Itop 50'I Well Destruction ❑ Well Diameter 9 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATIONrC REPAIR/ADDITION ❑ DESTRUCTION ❑ aNailabpelwithne200 feetit�ed;pubfic4, , t j Installation will serve: Residence f Commetc9al Othef x i Number of living units: Number of bedrooms j ` (•-- Water table depth Character of soil to a depth of 3 feet: ' SEPTIC TANK 0 Type/Mfg ' T F Capacity_/�� No. Compartments --�-�—^ t° , Method of Disposal PKG. TREATMENT PUT. I❑ ! l Vis, �r Distance to nearest:.4, Well -,..Foundation la Property Line za �`. _. DI.^sj,y -.,..n. . - Total length/size 6 LEACHING LINE Nei& Length-of-lines-_ .� r Foundation la f'f Property Line FILTER BED t ❑ Distance to nearest: Well-,Lp -- -la SEEPAGE PITS Depth Size Number SUMPS ❑L Distance f Foundation /o_ Property Line Z� G tance to nearest: Well_�Q�_ I k x DISPOSAL PONDS ❑ 1, -3 hereby certify that I have prepared this application and that the work will be done in accorda6e with San Joaquin county ordinances, state laws, and � :� rules and regulations of the San Joaquin Local Health District:., u� Homeowner or licensed agent's signature certifies the following: 111 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 taws of California."Contractor's hiring r to sub-contracting co trach competure nsa- certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p ! tign laws of California." . The applicant m all for I require inspections. Complete drawing on reverse side. n/�r / __. to a Title: - Da Signed X t �-- �u ._ FOR DEPARTMENT USE ONLY Data �1 � Area i Application Accepted by L 4 �P�, "'' Date� '%� .�' Final Inspection by Datet r rout Inspection by Additional Comments: Stk 4W6761 L) Lodi. 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 171Stk - Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 } FEE � RECEIVED BY DATE M'NO.INFOAMO DUE r AMOUNT REMITTED SH � B+ EH 13-24(REV.5/n5) 1tI - EH 14-26 - " - — - -• -. ._max. .