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APPLICATION FOR PERMIT 4C) SAN JOAnUiN LOCAL HEA TH DISTRICT 4A W 1601 E. HAZETON AVE., S iOCKTON, CA Telephone (209) 466 6781 : I (_3 �L .w' ! is��✓ 5.=_,-1«�} 1i �• 1;~ J'�1 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to c nstruct and/or install the work herein described.This appiicaion is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1 2 for well/pump and the Rules and tions of the San Joaquin te ues t fa � �-�rirc�, }AL Local Health District. FERMI '� LTH ES Job Address q Sc CAS f �1 q Jlw i1 Cit Lot Size PM AO,go�1s O 9 r-2 411 Address " rig !'OrLPe� G'fT•• Phone 0 3��^'�' Owner's Name .i rein%fi-, cog pIn g Contractor i> Address 6 r s License No. 3 Phon TYPE OF WELL/PUMP: NEW WELL I WELL REPLACEN ENT ❑ DESTRUCTION ❑ ! 04 0Mti6p#1116 PUMP INSTALLATION ❑ SYSTEM RE AIR ❑ OTHER $r W«1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROQLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Plot fA ❑ Domestic/Private h Gravel Pack ❑ Tracy I< Type of Casin PV e Specifications T (1 Public fl Other f1 delta Depth of Gra t Sea{ s Type of Grout /_;�. S�Approx. Depth I I Eastern; Surface Seal installed bv_ CO1`1 - I I Irrig�fat�igl p�.�, .. Re r'WoifDon' e` -k Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below } TYPE OF SEPTIC WORK: NEW (NST CATION 1.1 AEPAIRIADDITION l I DE TRUCTION I l (No septic syst permitted if public sewer is available n 200 feet.) Installation will serve: Residence— Co ercial Other Number of living units: Number of bedr ms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Calow' No. Compartments -� i PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well , ndation Property Line 'i LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED 1-1Distanceto nearest: I Fc n Property Line SEEPAGE PITS t l Depth Size 3 umber ' SUMPS ❑ Distant nearest: Well Foundatio Property Line { DISPOSAL PONDS ❑ f I hereby certify that I have prepared this application and thatithe 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 theperformance of the work for which this permit is issued, i shall not 3 employ any person in such manner as to become subject to workman's compensaticiii 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, l shall employ persons subject to workman's compensa- tion laws of California." The applicant must ca or all required inspections. Complate drawing on reverse si e. Signed X �yy �i? �.1-Y1[. 0✓� Title: tQ eC e lay i jZ Date: T� � — b2�a� FOR DEPARTMENT USE ONLY f IJ 1e, Application Accepted by `///"�''^"` ' "' Date �d Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ a It 835 6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Haz (ton Ave., P.O. Box 2009, Stk., CA 95249 FEE AMOUNT DUE MOUNT REMITTED CK RECEIVED BY DATE PERMITNO. INFO + CASH L., A ♦ EH 13-24 IREV.1/051 k EH t4.26 �