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�i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELT ON AVE., STOCKT ON, CA i !` Telephone (209) 486-6781 PERMIT EXPIRES 1'`YEAR FROM DATE ISSUED j� (Complete in Triplicate) ,. II ! - Application is hereby made to the San Joaquin Local Health District f!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. PM Job Address " a 1I City 1L p_ �/Lot Size Address + Phone Owner's Name � ' 4 Contract ddress -0 " J= License No' — Phone i TYPE OF WELL/PUMP:.- ;i: NEW WELL-❑ WELL REPLACEMENT ❑ r DESTRUCTION ❑ r 'g OTHER ❑ PUMP INSTALLATION ❑ li SYSTEM REPAIR ❑ F N k " DISTANCE TO NEAREST:' SEPTIC TANK SEWER LINES DISPOSAL FLD y " PROP. LINE ,N S FOUNDATION _AGRICULT11 URE WELL OTHER WELL - PITS/SUMPS:.= ,l INTENDED USE TYPE OF WELL PROBLEM AREA '!f CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom, d Manteca Dia- of Well Excavation .- ' - Dia. of Well Casing € S ecifications, ❑ Domestic/Private d Gravel Pack © Tracy I+-Type of Casing —�- P ` 1-1 Public [1 Other ❑ Delta Depth of Grout`$eal�_-:-i z' " `- Type of Grout` .j1 41'Appr�ox. D'e th I ] Eastern Surface Seal Installed by " ' - I I Irrigation .,P. r r yr Repair Work Done ❑ Type of Pump H.P. state Work Done_ I Well Destruction ❑ Weil;Diameter Sealing Material Itop 50'1 + '� �V t i Depth r Material (Below TYPE OF SEPTIC WORK: NEW INSTAL CATION EPA(R1ADi ITION DESTRUCTION I I (No septic system•'permitted if public sewer is ji available within 200 feet./ ` .Installation will serve: Residence vCommercial Number of living units: Number'of bedrooms Zee w Character of soil to a depth of 3 feet: 17� f' Water table depth I1�1 ents" SEPTIC TANK ❑ Type/Mfg ! Capacity Q No..Compartm f PKG. TREATMENT PLT. ❑ Method of Disposal hl -. � _ - / j Distance to nearest: WeII ice_}— Foundation E ;-� Property Line G� 0 LEACHING LINE -No. & Length of lines �r•=_ �- - Total length/size FILTER BED 11 Distance to nearest: Wefl Foundation Property Line _ ' SEEPAGE PITS 1w Oepth Size 3 _ Number .4e T - . >_- 4 I r SUMPS Cl Distance to nearest: Well�Q— Foundation Property�L'ine• Q� (- DISPOSAL PONDS ❑ '!�" 1 R" 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. h i ` [lowing: "N certify that in the performance of the work for which this permit is issued, I.shall not Home owner or licensed agent's signature certifies the fo employ any,person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring'or sub-comracting 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." I F k The applicant mu ca for ail-,re ired inspections. Complete drawing.on reverse side. Signed X Title:-� Date: r FOR DEPARTMENT USE ONLY 4 Application Accepted by !! Date7Area Pit or GrouInspection Date i -Final inspection by Date t' h � Additional Comments: T I k ❑ Stk 466-6781 ❑_Lodi.•,_369-3621...,..... _,D-Mentoba.823-71 ---ter'-Tracy--835-6385 1 I` Applicant- Return all copies to: Environmental Health PermitlServlIices 1601 E..Hazelton,Ave., P.O. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED} CASE+ RECEIVED BY DATE �., -PERMIT'NO`, � I INFO ii li rr.wr t + EH 13-24 tgEV.,i k 51 U , EH 14-26 \ "