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APPLICATION FOR PERMIT ; SAN JGAO.UIN LOCAL HEALTH DISTRICT _ 1601 E:-HAZELTON 5TOCKtw CA Teleptione-L' 09)'466-67$i-:"i IPERMIT.-EXPIBES 1 YEAR FROWtA* ISSUED (Complete in Triplicate) Application is hereby made to the San Joaqur-n_Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance 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. Zi N�IP7 City Lot Size /�/T� PM Job Address ' Owner's Name P-lsJb4� Address ry 8/ 1VOez#�� — Phone f � Contractor . '�'/ � Address 4 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION a f q i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER'❑ ti t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE f TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0-Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing LI Domestic/Private 171Gravel Pack ❑ Tracy Type of Casing 5pecificatidns 71 Delta Depth of Grout Seal Type of Grout l M Public C1 Other — 1 1 Irrigation _..Approx Depth I I Eastern Surface Seal Installed by I - r Repair Work Done El Type of Pump H.P. State Work Done _ .0 Well Destruction ❑t Well Diameters Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORk: NEW INSTALLATION 11 REPAIR IADDITION DESTRUCTION I I INo septic system permitted-if public'sewer is IT`S f available within 200 feet.) Installation will serve:, Residence Commercial— Other t Number of living units: Number of bedrooms •fy.�L-r; -� � l - Character of soil to a depth of 3 feet: 'Water table depth SEPTIC TANK ❑ Type/Mfg Capacity sNo.-Compartmentsf ! PKG. TREATMENT PLT. ❑ �T Method of Qisposal i �— Distance to nearest: Well�(� Foundation� _� Prop'ertyLine'�b LEACHING LINE ❑ No. 8 Length of lines f w rTotal length/size• t FILTER BED Distance t8 nearest: Well Foundation Proj,e`rty-NnW T —4 SEEPAGE PITS j I l Depth Size —N'iiriiber _..'��_ SUMPS � Ll Distance to nearest: Well Foundation Prpperty-Lin e"" DISPOSAL PONDS s ❑ t r f ' ; I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquincouhty ordinances, state laws,!and rules and regulations of the San Joaquin Local Health District. „-_, Home owner or licensed agent's signature certifies the following: "I certify that ifithe 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 i 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 compelhsa- tion laws of California.", The applicant must call for al required inspections. Complete drawing on reverse side.' Signed X �� C,�`� _ __�Title.: ��..._:�.-,...._..,,_. ..��__w.... ...,• Date: 10 F DEP MENT USE ONLY Q ; Application Accepted by Date v a Area Pit or Grout Inspection by Date Final Inspection b Date Additional Comments: D Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 D Tracy 835-6385 "r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201CK FEE i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. EH 14.2,8