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o V l APPLlCAT10 I FOR PERMIT J A I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL70N AVE., S70CKTON, CA Telephone (209) 466-6781 .1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete)in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of 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. f r Jab Address I City of size t PM ~ �7y�/� �N IM 7`OCA 70 � old 7 �►f) / //H92YZ Address i Owner's Name- �— Phone I� t Address go C _� License No. Phone TYPE OF WELL/PUMP: NEW WELLI WELL REPLACEMENT LJ DESTRUCTION ❑ PUMP INSTALLATION`J SYSTEM REPAIR © OTHER ❑ DISTANCE T'NEAREST: SEPTIC TANK �� SEWER LINES '�� DISPOSAL FLO. PROP. LINE f ' FOUNDATION i'�JO)Nf __ AGRICULTURE WELL OTHER WELL_tJnW. PITS/SUMPS INTENDEDTYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing L� Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications f"1 Public I F1 Other I l 1 Delta Depth of Grout Seal f Type of Grout I E Irrigation I oda Z_ApproxlDe th 1 I Eastern uHace Seal Installed by _ �y(, d r . l Repair Work Done 1r', Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 I Depth Filler Material (Below 561 TYPE OF SEPTIC WORK: NEW INSTALLATION I:I REPAIR/ADDITION I I DESTRUCTION [ I (No septic system permitted if public sewer is 11i ` available within 200 feet./ Installation will serve: Residence ` Commercial T Other Number of l,li.iving units: Number of bedrooms P Character of i soil to a depth of 3 feet: Water table depth SEPTIC TANK:. ❑ Type/Mfg h t Capacity No. Compartments l� I PKG. TREATMENT PLT. ❑ I� Method of Disposal IJ Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines IN Total length/size ❑ Distance to nearest: Well I Foundation Property Line FILTER BED 11, SEEPAGE PITS l I Depth IM Size I� Number a SUMPS �' LJ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ IA ! 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. III Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work far which this permit is issued, 1 shall not employ any person in such manner as toibecome 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 ofC The applica t ust call for all re d ins t ns. Complete wing on erse side. / Al /� Signed I Title: I _ �y * / ' (,� _t._ Date: _ IM R DEPARTMENT USE ONLY Application Accepted by lk, Date Area F Pit r Grou f Inspection by Date Final Inspection by Dat Additional Comments: �❑ Stk 466-6781 ❑ U, anteca 823-7104 IN ❑ Tra 835-63$5 Applicant - Return all copies to: Environmental H alth Permit/Serv' as 1601 E. Haza(ton Ave., P.O. Box 2009 Stk., CA 95201 dTFd /6om G��r oB��6.s/ '�a'o 6��odfi tee%! J"��/. l� �s ers`�� /Ccrs •GEv'4c�_ A-11r,��6 FEE — Yr — INFO AMOUNT pUE Ii14/IOUNT REMITTED CASH RECEIVED BY GATE ?ERt4t1lE7'NO. 1'EIdFF✓ +,EH13-2/IREV.1/K5Y EH 14-26