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APPLICATION FOR PERMIT 4AN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTOe AVE., S -6781 N, CA �� PID Telephone AVE 4STOC 1 (Ja V PERMIT EXPIRES TYEAR 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. Job Address City Lot Size PM lam, Owner's Name -Address._. /�C�K+X �/.1x1y L� Phone Contractor e� Address w.AaX �J 2 License No. - Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ ` SYSTEM-REPAIR 0, OTHER ❑ DISTANCE 1ro NEARES TANK SEWER-LINES DISPOSAL FLD. PROP. LINE FOUNDATIO AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBEA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Castn Specifications 11 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout - I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Cl Well Diameter Sealing Material (top 501 Depth -_ Filler Material (Belo q TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: - Residence_ Commercial_ Other Qr 61 ,, �y� •, Number of living units: Number of bedrooms ----- _____.-...._.R.-_ _ Character of soil to a depth f 3 feet: Water table depth 6EPFfe;F*l depth h Capacity /.�-� 4: No; Compartments PKG. TREATMENT PLT. ❑ Method c Disposal Distance to nearest: Well Foundation - Property.One, ez-Z' l�A'��7Yr�' I LEACHING LINE ❑ No. & Length of lines Total length/size'— FILTER ength/sizeFILTER BED ❑ Distance to nearest: - Well Foundation Property,Lim SEEPAGE PITS II. Depth Size Number SUMPS ❑• Distance to nearest: Well Foundation Property,Line DISPOSAL PONDS ❑ 1 hereby certify that 1 have prepared this application and the the work will be done in accordance with San oaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health-D3trieE— ------ 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 anyperson i uch manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the followi "I certify that in the performance of the work for which this permit is issued, I shall employ Arsons subject to workman's compensa- tion laws of Calif a." The applicant Us call for all requi pection mplete drawing on reverse side. / Signed TRS Ie ^--�`'J ��o Date: "Ip—�!6 � FOR DEPARTMENT USE ONLY _ - Applicatio Accepted by M_ YP- "^�+�+ Date 5�19-RR Area le Pit or Grout Inspectio Date Final Inspection by Date Additional Comments: �C.) ❑ Stk 466-6781 ❑ 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, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. a.EH 13-1x IREY.i/x51 - 7_0 EH N-Ia CCC l/ K-