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, 1 APPLICATION FOR PERMIT I . SAN JOAQUIN'LOCAL'HEALTH DISTRICT . 1601 E. HAZEL i-ON„y AVE.-,.,ST; QCKTON, CA -Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED''` ill. (Complete.in Trlphcate) 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 Ryles and Regulations of the San Joaquin Local Health District. Job AddressCity Lot i z?•ie PM Si -Owner's Name J? Address' -YPhone Contractor r' Addressi License Na. - TYPE OF WELL/P P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE ..FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ 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 - ❑ Ii rigation --Approx. Depth ❑-Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump �` H.P. State Work Done ` Well Destruction ❑ Well Diameter Sealing Material (top 501 e Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑•, REPAIR/ADDITION JIC DESTRUCTION ❑ (No septic system permitted if public sewer is 1 ,,fr. available within 200 feet.) Installation will serve: Residence._..,.,'`Commercial_�1” Othdr,' Number of living units: Number of Brooms ' Character of soil to a depth of 3 feet: -' i'a-ice Water table depth SEPTIC TANK -Q� Type/Mfg m _ �bapacity No. Compartments PKG. TREATMENT PLT.❑ j Method of Disposal ' Distance to nearest: Well Foundation Property Line ` r 1 t• `� l � ?, , i LEACHING LINE t +; +"p' No. & Length of lines"I t"W""'"""' Total length/size t FILTER BED '+. ` fi+� (1_ Distance,tomearestf'l• Well 1 Foundation Property Line SEEPAGE PITC ❑ Depth * Size Number SUMPS ,.; : r'^..r.f❑; Distance to neare4 A Weil Foundation Property Line DISPOSAL PONDS p I herebycert - p`p`- pp J rfy'ihat I-have're'ared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws, and t rules and ragdationstof the San Joaquin Local Health District. Home owner or licensed egent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, 1 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 fallowing:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." \ 1 The applicant must call for alPI&Wired inspections. Complete drawing on r _arse side. Signed c s r Title:a '+^. v� � 'til V ^ ''(!�, � ��`�'-,;t. ' Date: +r;a FOR DEPAkTMENT USE ONLY i tA�jllication,Accepted by �P Dae 7 Area + �At or Groutmion by # ate, ` pectr- -`Firtal'f { � Date kXkdditlonalCorQint : - _ O Stk '823--7104 466-6781' ❑ L i 369.3621 ❑ Manteca`"r823-71041 lam❑Tracy 835 63x35 ` Applicant- Return all copies to: Environrlilental Health Permit/Services 1601 E. Hazelton Ave:, P:O. Box 2009, Stk., CA 95201 {`A.t. n n }wi -�< •� "{'�!is �•..,a.�-w--'- �4?- �`�.� FEE .AMOUNT DUE AMOUNT REMITTED . CK 0 RECEIVED.•BY,. DATE. PERMIT`NO. INFO CASH' i ,1 i +EH 13-2A IREV.:- rat) ...,.. ..,,� •..ti.�.. ....,w-�.... •,! � Eaze -CIS n H l