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` "' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., S OCKTON, CA Telephone (209) 46 -6781 rn� PERMIT EXPIRES 1 YEAR FRCM DATE ISSUED (Complete in Tripli ate) Application is her eby 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. Local Health District. m549 for sewage or No. i 2 for well/pup and the Rules and Regulations of the San Joaquin Job Address !7 f I i. City Lot Size-Z , d I PM Owner's Name i\ 41 rt Address I CC' ro I .i �txSrr [ Phone ��C �� ,,'Z .fT u9 9y.S_3� Contractor e- C Address rod License No. �. Phone (S -v TYPE OF WELL/PUMP: NEW WELL � Ii WELL REPLACEM NT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ rrlUrr`17O DISTANCE TO NEAREST: SEPTIC TANK _-?'-� >r OTHER ® (' SEWER LAVES 7�sr �- DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSIr INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT! N SPECIFICATIONS L] Industrial ❑ Open Bottom ❑ Manteca ' Dia. of Well Excavation C ' 1 Dia. of Well Casing fl Domestic/Private Q'Gravel Pack ❑ Tracy Type of Casing -5 O P v L. Specifications I'I Public fa Other 1'l Delta Depth of Grout Seal Z �, AL �.,.,� I t Irri tion 11 p — Type of Grout G fy?l/hPvr�r-2, �^an �7da SDZtApprox. Depth l I Eastern Surface Seal Installed by C r[ O r lN�7r'`�t— Repair Mai U Type of Pump H.P, State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50'1 f Depth Filler Material (Below 501 TYPE OF PTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DEST UCTION I I (No se system permitted if public sewer is av i le within 200 feet.) Installation wl serve: Residence_ Commercial_ Other Number of living nits: Number of bedrooms In Character of soil to depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal [L Dis ce to nearest: Well Foundation Property Line LEACHING LINE L� No. & Leng of tin Total length size , FILTER BED 1-1 Distance to ne Well Foundation Property Line SEEPAGE PITS I I De Size _ Number SUMPS 1.1 istance to nearest: Well ion Property Line DISPOSAL PONDS -1 I hereby certify that I have prepared this application and that the,lwork wilt be done in a cordance 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: certify that in the pe ormance 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 perrniI s issued, I shall employ persons subject to workman's compensa- tion laws of California." I; `f The applicant must call for all a uired ins 06 L I I, c 0 inspections. Complete drawing eA 6-ve ee-erde. Si ned X // - I/ g 4 C e�)r P [� r?t . Title: �Pc-I 1'rL l fir't)f Date: t�I.30/9� 14Z1 �. �--r`- V FOR pEPARTMENT USE ONLY Application Accepted by ( ""fix Date I Area Pit or Grout Inspection by Date Final Insp ction by Date c Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk- CA 95201 �v`'T+r" � �`m`^%Sv = I e� i ! FEE AMOUNT DUE AMOUNT REMITTED k INFO R CEIVED 8 DATE PERMIT'NO, EH 1721 TREY.lin 6! �J• I ��/� �Z-So I EH 112E