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APPLICATION FOR PERMIT SAN JOAQUIN"LOCAL HEALTH DISTRICT 1601-E—HAZELT-ON-AVE-, ST-OCKTONr-CA ' Telephone 12091 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 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. A/lam 7,0 Job Address t 4ti� a L.++ �L7 r'{�k 1+�� City xb Lot Size PM Owner's Name At L h F I'4E S�_ Address 1,10-0 L, "�Q Nt`IP�?+��T Phone 7-.a) � I Contractor Lgsr�,W Ai T anLIAddress SD license No. 3Ak'a Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL', ' PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout .❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump" H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material (top RY) v Depth FilleMaterial (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR; ODITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) t Installation will serve: Resid nce��Commercial`� �Oth r Number of living units: Number of bedr ms Character of soil to a depth of 3 feet: -. il..k Water table depth SEPTIC TANK &-- rype/Mfg CQF, ;4 Capacity� � No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Disiance to nearest: Well Foundation Z Property Line LEACHING LINE DL—#4e. & Length of lines 45 r Total length/size FILTER BED ❑ Distance to nearest: Well Foundation �b Property Line SEEPAGE PITS N,-V_,pth Size_ _� Number SUMPS ❑ Distance to nearest: Well .Ino Foundatit Property Line f o o 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`su'6J6 t"to workman's compensation laws of California."Contractor's hiring or subcontracting signature certif a following:"I n'fy that in the ormance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws o lifornia." T applican mu call for all aqui din tions. m e drawing on si Signed Title: - __ _ Date: OR DEPARTIVIEN USE ONLY l Application Accepted by � Date �" Area Pit or Grout Inspection by DateFina! nspection by Date Additional Comments: kpj .1 -9 N ❑ Stk 466-6761 Lodi 1 ❑ Manteca 822b104 ❑ Tracy 835-638 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 RECEIVED BY DATE PERMIT NO. INFO CASH' :y,y. + EH 13-24(REV.1/e5l 5-775 EH 14-28 i