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S � APPLICATION FOR PERMIT I; SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., ST.00KTON, CA (�GAte N7' Telephone (209) -67ST' �Y4 E3 3Y � ED PERMIT EXPIRES 1'Y,EAR FROM DATE ISSUED ; pUG 2 (Complete in Triplicate) Eft-. Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worlicationmade in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rule ,p Joaquin ,i Local Health District. } C S , Job Address /""gam" 1/!/\ Gity Lot Size PM j F h Owner's Name L 1 900 �� + IO Address �¢¢ i f u✓"fes. ��Oc+jL phone I'l t Contractor Address ZQ ! tD License No.283a2 Phone( TYPE OF WELL/PUMP: NEW WELL L1 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER /Jfoyjjpi�i DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP. LINE P' N` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i I" INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation J�//� Dia. of Well Casing p i. ! ($Domesticrivate Gravel Pack ❑ Tracy Type of Casing �� Specifications s 1'1 Public ❑ Ot¢er F Delta Depth of Grout Seal ' Type of Grout ae'll kWC&A I I Irrigation Depth Depth I i Eastern Surface Seal Installed by �a*3' Repair Work Done ❑ Type of Pump / o r H.P. State Work Done i/ Well W Destruction ❑ Well Diameter. Sealing Material ('top 50'I ,�/�.._- Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1' REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is --available within 200 feet.l Installation will serve: Residence_1 Commercial— Other ' j Number of living units: - Number of bedrooms l Character of soil to a depth of 3 feet: # Water table depth ; SEPTIC TANK ❑ .. Type/Mfg'i Capacity No. Compartments r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line F :I LEACHING LINE - ❑ No. & Length of lines Total length/size FILTER BED ❑ " Distance t6 nearest: Well Foundation Property Line I SEEPAGE PITS { 1 Depth I Size �. Number i i SUMPS L1 Distance to'nearest: Well Foundation Property Line I 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, state laws, and ` I rules and regulations of the San Joaquin Local Health Diltrict. 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-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 laws of California." ." I Thea licant YC !0��ruired ins �pp epections. Complete drawing on reverse side./S(3,f 1 Signed X _ Title: /Lill pate: z J; FOR DEPARTMENT USE ONLY Application Accepted by � �, is9017 Date, Area Pit or Grout inspection by�' � � Date ��Finai 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, Silk.; CA'95201 :.E FEE w INFO AMOUNT DUE AMOUNT REMITTED KSy RECEIVED BY DATE PERMIT"NO. rte' 10 --_> f 3� ♦-EH 13-24(REV,r/n 5) V i� EH 14-2 16 - _ - (