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II ' AA�I ! APPLICATION FOR ERMIT SAN JOAdUIN LOCAL HEALTH DISTRICT i ,I 1601 E. HAZE T ON AVE., S OCKTON, CA s Telephone (209) 466-6781 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 he n This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1 for well/pump and the Ryles R ulat the San Joaquin .Local Health District. Job Address Cite Lot Size Owner's Name �� Address ZZ j 7 Phone Z [[ ri r /S ZZK Contractor �.'T7� Address 1 I J a 6 itense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ i SYSTEM REF AIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTI N SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well EKC8Vation —114C Dia. of Well Casing ❑ Domestic/Private . ❑ Gravel Pack ❑ Tracy 11 Type of Casing_ vJ Specifications : �Q ❑ Public 3 LOther ❑ Delta Depth of Grout Seal W Type of Grout ted' ❑ Irrigation NJpFcr 3rab1'e---Approx. Depth ❑ EasternSurface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top W) r Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION© DESTRUCTION ❑ j(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 ' t Character of soil to a depth of 3 feet: .r Water table depth SEPTIC TANK ❑ Type/Mfg ! l _ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. &Length,6f lines I I Total length/size -, F. FILTER BED ❑ Distance to nearest: Well ` " - Foundatio Property One ti,1 SEEPAGE PITS ❑ Depth Size 'r Number SUMPS ❑ Distance to nearest: Well Foundation Property Lyne DISPOSAL PONDS ❑ tit. I hereby certify that I have prepared this application and thatIlthe work will tit7done 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 fotlowing: "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." Contractors hiring or sub-contracting signature certifies the following: "I c rtify that in the performance of the lwork for which this per nit is issued, I shall employ persons subject to workman's compensa- tion laws of California" The applicant mus for all required ' pec- s plet f drawing on reverse sic e. _ _ r Signed Title: Date: n FOR DE RTMENT USE ONLY Application ccepted by ✓ Date Area Pit or Grout Ins y Datei t%O��•�Final nspeciion by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca U0104 r y 935 6385 wp r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 25M, Stk., CA 95201 PS I FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CASH �rI p Q� + EH 1324(REV.x185) if f rA� rJ—^7jQ 0,�`SS5 EH 1426 1 /w I. k