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d i1 APPLICATION FOR PERMIT . f SAN JOAQUIN LOCAL HEALTH DISTRICT 1 N � Cbry 1601 E. HAZELTON AVE: 5TOCKTON, CA Telephone.(209);466 6781 NOwv PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in T4plicate) S' . 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 Nd. 1862 for well/pump and the Rules and Regulations of the San Joaquin ,I Local Health District. Job Address 11 E� City Lat Size ! � PM I Lob l Address Owner's Name �CO C < Phone Contractor -�=Address tLicense No. Phone TYPE OF WELL/PUMP: NEW WELL EJWELL REPLACEMENT ❑ DESTRUCTIO PUMP INSTALLATION ❑ t SYSTEM 'REPAIR El-',' 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 �J El Bottom Ll Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private , ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public -❑ Other � - t-7 Delta Depth of Grout 5ea1 i ' I I Irfi ation' i h Type of Grout _ g _-Approx. Depth -I"I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H P li State Work Done_ Well Destruction ❑ Well Diameter ;'. Sealing Material (top 501 i50 \, 1 Depth *Filler Material IBelow�50') �; ! TYPE OF SEPTIC WORK: NEW INSTALLATION C1 REPAIR/ADDITION l 1 DESTRUCTION I septic system permitted if public sewer is I° 47 Installation will serve:—Residence �L�mercial— Other- available within 200 feet,i - Number of living units: Number of.bedrooms E 'moi ! i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type)Mfg - —' Ca city—L, -- p Y No. Compartments PKG. TREATMENT PLT. Q -v { 4 Method of Disposal iDistance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER SED ❑,. Distance to-nearest:' Well Foundation Property Line, SEEPAGE PITS i I Depth I Size :i Number 1 SUMPS i' 0 Distance to nearest: Well Foundation DISPOSAL PONDS 171I Property Line 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 Locai Health District. 19 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 an s C—CP y person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature alufres the following: "I certify that in the performance of the work for which this tion laf Californi permit is issued I "shall employ persons subject to workman's compensa- � — -- The applica u all fo all quir ins do Complete drawing on pe side r Signed Title: l .� Date:' g a 1 F TMENT USE ONLY r , Application'Accepted by Date 3 —a -3— f .Area Pit or Grout Inspection by DateI-'�l FinaLinspection by C3 Date -zf Additional Comments: ' a ❑ Stk 466-67$1 El Lodi 369-3621 ❑ Manteca 823-71 ❑ Tracy 835-63$5 . A e Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Ave., P.O..Box.2009, Stk.,-CA 95201; _ t�i•e- ��.tr,�n L� °� � ►'Loyd ' L-�C-' Co Y, FEE Ai410UNT DUE' x ` AMDUNT'REMiTTEDff INF 1" RECEIVED 9Y DATE PERMIT'No. I�lucU! s > + EH 13-24(REV.t i H 51 s � —� /' - EH 14-28 `(,Jf' [LJ I•. • I