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APPLICATION FOR PERMIT ib :3 -7/o-7 F x 4— SAN JOAQUIN LOCAL HEALTH DISTRICT l 1601 . HIAZELT:ON AVE:-S70CKTON, CA ! �w'"Telephone'{209)t466-6781 PERMIT EXPIRES 1 YEARTROM DATE ISSUED' ' r - 16mplete in Triplicate) — r,: ,..} � '' .>< 7� j ,...' i''i k ";'_. s 4l.t A.y , • i :. ;�. W ;�. ,.;r S7, 'r'�.. .7�fi L.€',. 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 Sen Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. j " rj*V 011 .fob Address �+ �4 Ci lie PM Owner's Name W411Phone f! it r ContractorAddress.,] {iU License No. Phone TYPE OF LL/PUMP: N WELL El 4/1 ;WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER D. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE x. FOUNDATION; AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Indd ial i ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1J C�^Domestic/Priv Vate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public I ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation pprox. Depth ❑ astern Su b eal Installed by Repair Work Done 1 Type of Pump H.P. State Work3ne - rk Well Destruction- ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 r TYPE OF SEPTIC-WORK: NEW INSTALLATION ElREPAIR/ADDITION LlDESTRUCTION ❑ INo?septic system permitted if.public sewer is 1 available within 200.-feet.)�7� Installation w serve: Residence Commercial_ Other `f1 "�` Number of living-unitsi Numberof bedrooms Character of sow o a depth of 3 feet: 4 Water table depth SEPTIC TANK!, ❑ Type/MfgCapacity No. Compartments PKG. TREATMENT PLT. ❑ I MetlQ,of Disposal 1 Distance to nearest: Well Foundation Property Line-, LEACHING LINE ❑ No._&_Length.-of-lines — 'w — '—"" "` ` "-fotal_le.ogthlsize ''p '4r FILTER BED ❑ Distance to nearest: Well �_Fbundation Property Line SEEPAGE PITS ❑ '`Depth �� ize a Number •f .. SUMPS ❑ 'Distance tolnearest: Well Foundation Property Line DISPOSAL PONDS ❑ I r hereby certify that) have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulati ` an Joaquin Local Health District. iI Home aw or licensed agent's nature;certifies th following "I certify that in the performance of the work for which this permit is issued, I shall not 1 employ ny person in such manner a to become su ct to an's compensation of California." Contractor's hiring or sub-contracting signature certifies the following:"'I certify that' he`perfor e e w k for whi this p it' issued,I shall employ persons subject to workman's compen tion law, of California." The appli nt mustca r aired in ete Ing n rever I r' Signed ' Date: s FOR DEPARTMENT USE ONLY Application Accepted by Date Area i Pit or Grout Inspection by Date Final Inspection by _ Date `D Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El-Tracy 835-6385 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DAI. PERMIT'`NO. INFO + EH 13-241REV.1/ssY JA.�'• EH 1426 Q L _