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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DIST,_RJCT, HAZELTON AVE., Sl`OCKTA ( Telephone (209) 466-6781 PERMi","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/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. �q nn J� Job Address 1.2V A) AJesl<AV, City Lot Size . q PM Owner's Name LUA t i ik Address es At- Phone As .- r Contractor's Name License No. �.Z,� _ 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 _ 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 \ ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 0 Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type'of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Q Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: ..NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units:�_ Number of bedrooms Character of soil to a depth of 3 feet: Watertable depth SEPTIC TANK ®/Type/Mfg C r Capacity / No. Compartments PKG. TREATMENT PLT. ❑ Method of Dop9sal Distance to nearest: Well Foundation Property Line _ 56- LEACHING LINE No. & J Length of lines zz � 9 �f.�' TotallengthJsize . FILTER BED l Distance to nearest: Well Foundation of© .f Property Line SEEPAGE PITS &K Depth 25 Size 36 Number SUMPS [!T' Distance to nearest: Well D ' Foundationc5� Property Line DISPOSAL PONDS ❑ - 1 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 hinni 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 callall squired inspections. Complete drawing on reverse side. Signed X Title: O_A)iE)e O— Date: 6 J' FOR DEPAR MENT USE ONLY Application Accepted by Date H, Area Pi or Grout Inspection by Date Final Inspection by Date Additional Comments: O Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVEQ BY DATE r PERMIT"NO. +EH 13.24(REV.10/83) EH 14.28 S