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t _ APPLICATION FOR PERMIT '•r`�=� . S N JOAQUIN LOCAL HEALTH DISTRICT 1T1 E. HAZE T ON AVE., SOCKTON, CA +� Telephone (209) 466-6781 - �� 4 PERMIT-EXPIRES EAR FROM DATE ISSUED ICornplete in Triplicate) rZ� ��ZctGC2�Y �✓leD= 4 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 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. Job Address n CityLot Size r Owner's Name C / Address F0• SOX 251D &*l^_h C& CN901 Phone qfS 7 ply ��L_ 1' "510 NIZA Ctrl s� f3CTI c_a Address �7 0?T0 Coniractar —�L3._� Q, KOX ,�S L' License No. SIQOD4 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_ I I Irrigation _..Approx.{Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Wel! Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Bel w 501) _ TYPE OF SEPTIC WORK: NEW INSTALLATION. REPAIR)ADDITIONIX DESTRUCTION l I INo septic system permitted if public sewer is filable with; i.1 Installation will serve: Residence_ Commercial Other , �� N Number of living units: Number of bedrooms ' l Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mf ` ! F 9' Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line l f LEACHING LINE ❑ No. & Length of li es �[ Total length/size / ILTER BE ❑ Distance to nearest: Well ou�tign Property Line SEEPAGE PITS I I Depth Size Number 1 SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that t have prepared this application and that the work will be dons in accordance with San Joaquin county 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 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: "!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 The applicant must call for all required inspections. Complete drawing on reverse side. Signed X L i ate: FOR DEPARTMENT USE ONLY Application Accepted by 4,21/-5� Date / �of Area ' Pit or Grout Inspection by ate ,,/� �rrFin�alylnspecti�on by Date ��/G Additional Comments: ' °� �� //V S/ !7' 1'� /fir Gzd a`�srr' 'E ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 13 Tracy 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.-Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AM�OUjNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +.EH14-241AEV.t/x51 I L (� lQ� 1/0-17��8� EH 14-2t3 [ 1 i