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APPLICATION FOR SpAf4r UTIN d%NW_RMLIC HEALTH SERVICES SAN JOAQUIN LOCAL HEALTH �.'hR/iP4gA7.ENTAL HEALTrt TSION 1601 E. HAZE T ON AVE., STOCKY CA Telephone (209) 466-6781 ECIAL PERMIT 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/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 �n4d W� CMW+k AiA_ CitySx�_ t 1 N Lot Size PM Owner's Name S LL W. Address • � *2:3 , CD�gla, phone 1`9 11 1-14 Contractor rimAddressa License No. �5 Ph 0 to a- �-� TYPE OF WELL/PUMP: NEW WELL ❑ (moi WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION El SYSTEM �,REPAIR �0 OTHER Q/f*'Jf DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES —2-n-VA- DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation / � Dia. of Well Casing LI Domestic/Private ❑ GG I Pack ❑ Tracy Type of Casing PV G Specifications ('1 Public 1�l'Othvr [l Delta Depth of Grout Seal �3 Type of Grout •,�V(__ t 1 1 Irrigation '�Approx. Depth I I Eastern Surface Seal Installed by 5• .1- l/ j �� ! Q©�L N t ,`� Repair Work Done 11 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 13 Z�/V Ill '1','C Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION l I (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: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size _ FILTER BED 11 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 11 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 Dilarict. 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 c//all for all required inspectio mplete drawing on reverse side. Signed �L� `t�'� Title: Date: .6 _G 7_%rl OR DEPA TMENT USE ONLY mLq�] Application Accepted by rDate / ( Area � � q Pit or Grout Inspection by Dat Final Inspection by Date 78F�ft;./ JiAQT# ILACln C -E \01 ❑ Stk T-466-6781 ❑ Lodi 36993Ul ❑ Manteca 823-7104 ❑ Tracy 835-6385 S Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952( r 3�15 ` IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH13-24(REV.1 i x 5) 9q,� 00 11sitorC q.1 EH 14-28 6 6 ��f�