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APPLICATION FOR PERMIT SAN JOAQUIN LOCAVE ES RDISTRICTLTH OCKTON, CA 16()1 E. HAZE i ON Telephone (2()g) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED i (Complete in Triplicate) application s San Joaquin Local Health Distract for a permit to cohstruct and/or install the work herein described of the made to the 5a ordinance No.549 for sewage or No. iBrr2 for well/pump and the Rules and Regulations of the San Joaquin Applicat;on is hereby urn County Or made in compliance with San Joaq k PM --- t Local Health District. I City �� Lot Size� — �7` Job Address �a - � Phone Address Owner's Name �Phone L License No rll�l )Nu{M p' Address 5 pESTRUGTION LJContractorWELL REPLACEMENT a OTHER ❑ �� NEW WELL k TYPE OF WELL/PUMP: SYSTEM REPAIR d pROp. LINE _—�' PUMP INSTALLATION _� — DISPOSAL- SEPTIC ISPOSAL FLDW,� —� PlTS15UMPS � ETHER WELL-00A) k DISTANCE TO NEAREST:.SEPTIC TANK —. SEWER LINES AGRICULTURE WELL FOUNDATION S` TYPE OF WELL PR013LEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing A INTENDED USE p Manteca Dia. of Well Excavation Specifications �ry ❑ Industrial ❑ Open Bottom Type of Casing Type of Grout F C`kGravel Pack ❑ Tracy DomesuclPrivate ❑ Delta Depth of Grout Seal I Cl Other Surface Seal Installed by i'1 Public rax- De th i I Eastern p,pp / ` State Work Done— I I Irrigation H.P. Type of Pump Repair Work Done a Sealing Mateflal (top.50.1 f. 1 Well Diameter �-- t Well Destruction ❑ Faller Material /Below 50'1 U Depth » tic system permitted it public sewer is available within 2�}feet.) TYPE OF SEPTIC WORK: NEW INSTALII�TlON l;i REPAlR1A1]DITION l S r pESTRUCTION l I l o sep Residence Commercial Other Installation will serve: IWater table depth \ Number of living units: Number of bedrooms 1— Character of soil to a depth of 3 feet: Capacity---- No. Compartmen¢:. El Te; Method of Disposal SEPTIC TANK PKG. TREATMENT PLT. ❑ Well — Foundation.�-- Property Line Distance to to nearest: t } 11 Total length/size ❑ No' & Length of lines Foundation ��— property Line__�� V LEACHING LINE — ----- ClDistance to nearest: Wellw R FILTER SED =1 'd . . :Eb Number i I Depth Size SEEPAGE PITS Foundation �� property Line Ll Disiance to nearest: Well��— sr SUMPS ❑ i DISPOSAL PONDS i certify that I have prepared this application and-that the work well beldone in accordance with San Joaquin county ordinances, state laws, an t ^ l hereby c Y rules and regulations of the San Joaquin Local certifies Health DitracL9 ensa- o workman's compensation laws of ed,I ha ll employ personsrring OF subject to workman'scompensa- Home owner or licensed agent's signature certifies the fol`owin `V certify that in the performance of the work for which this permit is issued, signature shall no employ any person in such manner as to become sublet certifies the following: "I certify that in the perfo(mance of the work for which this permit is issued,I she employ lion laws of California." 27il� The applicant t call tar all required inspecti ns. Complete dr i Date: Title: iV Signed X --"s""'_"" : FpPARTMENT USE ONLY 1\',� Date Area i - ?L Date /'z Applicat Accepted by Final Inspection by Date�� Pit� Inspection Additional Comments: ❑ Lodi 369-3621 ❑ Manteca 829-7104 11 ❑ Tracy 835-6385 Hazelton Ave., P.O. Box 2003. ❑ Stk 466-6781 Stk., CA 95241 Applicant - Return all copses to: Environmental Health Permit/Services 16011 E. _ GATE PERMIT'NO, CK RECEIVED�V 17 -- s FEE AMOUNT DUE AMOUNT REMC 'SFr ITTED I INFO r d f .� —3 +AH 13-24,1 REV S/rs51 �y L EH 1428