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r) APPLICATION FOR PERMIT -� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.S {fi AQIIA►T6'@UNW.pM1CHEALTHSERVIaS Telephone 12091 46 -670MRONMEWAL HFALTH DNISION PERMIT EXPIRES 1 YEAR FROM DJqJbVJVtWPERMIT ]�D I l T'T ICompiete in Tripli ate/ 1 �L�., Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. THs application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1162 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ,{. Jots Address trQV OO E '�]`'G�Ju m 12 L _ Ci y L n.4', _ Lot Size/g3 � 1 9 IPM LJ Z;IOwner's Name V+ V"�r Z- Address rca Phon o og � 6 Al W e5T HA MAT 233 ,~ s,` tC ar ovq 654g19 q16 6387 b Contract Address men a o. 1164, 0 i;3Phone3:44 4 TYPE OF WELL/PUMP: NE ELL X WELL REPLACEN ENT ❑ DESTRUCTION JRL PUMP INSTALLATION SYSTEM RE AIR ❑ OTHER 0' Ivor.•4// L-le'/5, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.r� _ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT ON SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation i pia, of Well Casing Domestic rivet 18f Gravel Pack ❑ Tracy Type of Casi g�r`ne� 4t7 �� Specifications M Public fl Other 6=STRUCTION Depth of Grout Seal Type of Grout W'� t� I I Irrigation 7Q�•'�pprox. Depth ISurface Seal Installed by Repair Work Done ❑ Type of Pump �i_AState Work Do e el estruction Well Diameters Material (top '1 c Mflyy Depth - aterial (Below 'INEW INSTALLATION DITION l I DE 7RUCTION I 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/MfgOCT rtments PKG. TREATMENT PLT.❑ LIL W1�Vsat Distance to nearest: Well -NOWNWrs Z OIC LEACHING LINE ❑ No. & Length of lines Total length/site FILTER BED ❑ Distance to nearest: Well Foundaticii i Property Line SEEPAGE PITS t I Depth Site Number SUMPS ❑ Distance to nearest: Weil Foundatiori Property Line DISPOSAL PONDS ❑ 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. 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 compensatior 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 per it is issued,I shalt employ persons subject to workman's compensa- tion laws of Caiifomia." The applicant must call for all required 'nspections Complete drawingo reverse si e. f�7 Signed X� f�,Mrsra Title: Pr •0 V L T/fib ' F SPAR USE ONL Application Accepted by Date 7- /G Area el- 3-3 IWV Pit or Grout Inspection by Date Final nspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tray 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK CASK RECEIVED By DATE PERMIT'NO. INFO EH 13-24(REV.r.rs) 60 EH 14-26