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k APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE, ST OCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE'ISSUED f (Complete in Triplicate) it. 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 ; s � YCit+� /0 Loot Size '�O'fX 3oc> PM Owner's Name _�J` L �i l //%rA�dres/5oe /.Z Z� ��y �c-'O( Phone �'z'"Z`S 3 y � Contractor Address (r� License No: Phone T WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARESTIC TANK SEWER LINES DISPOSAL FLD. _ PROP. LINE ; FOUNDA AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE' TYPE OF WELL P AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing ❑:Domestic/Private ❑ Gravel Pack ❑ Tracy Type o nSpecifications ❑ Public ❑ Other ❑ Delta Depth of Grout Se '' T r p Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done I^ Well Destruction ❑ Well Diameter 5eaiing'Material (top 50') �V Depth Filler-Material"f Below 50'1-'=---- - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑„ DESTRUON IN septic system permitted if public sewer is ilable within 200 feet.l Installation will serve: Residence_ Commercial Other t Number of living units: Number of bedrooms r � ' 1 Character of soil to a depth of 3 feet: t Water table depth ^ SEPTIC TANK ❑ Type/Mfg t Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well : Foundation Property Line 3 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: well-, Foundation Property Line PITS --`"''"''"❑' Depth - """ Size - Number , SUMPS ❑ Distance to nearest: Well Foundation, Property Line I DISPOSAL PONDS ❑ r t I r f 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 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: "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." The applicant must call for all requir d inspections. Complete drawing on reverse side. � ` r Signed >��i , a � Title: CJS, Date: J ..&27 FOR DEPARTMENT UJSt ONLY '9 Application Accepted by Date 3 47� Area 6/ Pit or Grout inspection by bate Finai Inspection by Date -1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi -469-5621 el Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. ly INFO + EH13-24fREV.iiHs1 ' �, Qq�� $ &—? f EH 13-28 (,