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. f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZELTON.AVE., STOCKT_ON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _',-w - , (Complete in Triplicate),7. :Cr 1 ... . . 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.. ...rfr E?l. t i. I�� Job Address �Q 3 Q © h pt r Ci C Lot Size AR0 PM144 I Owner's Name Cl Teles JorJArV Address VIV; •' �1 Phone 7 06 Contractor's Name License No. Phone " 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 V f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS O f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well-Casing Z:_ y ❑ Domestic/Private ❑ Gravel Pack _ ❑ Tracy --Type of-Casing Specifications �.C] _w.. . ❑ - -Public- --- � " Other El Delta .Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth .❑ Eastern Surface Seal Installed by e- -Repair Work Done ❑ Type of Pump H.P.' State Work Done .r Well Destruction ❑ Well Diameter Sealing Material (top 501 F j Depth Filler Material (Below-50'). TYPE OF SEPTIC WORK,: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION 10o septic system permitted-if public sewer is available within 200 feet.) ` Installation will serve: Residence_ Commercial_ Other ,� f Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth f SEPTIC TANK ❑ Type/Mfg 'Capacity No. Compartments' PKG. TREATMENT.PLT, ❑:-� #. Method of Disposal > Distance to nearest: Well --'`Foundation Property Line 'r LEACHING LINE »A ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line + SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 'Distance to nearest: Well Foundation _ Property Line DISPOSAL PONDS ❑ 1 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 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 permit is issued, I shall employ persons subject to workman's compensa- tion-laws-of-California: �-' V- .- -— _ . . -- m_ ^" - - I . -, — 4G.� The applicant must call for squired 'nspections. Complete drawing on.reverse side. Signed '' Title: Date: FORD PARTMENT USE ONLY (� s Application Accepted by Date 7— I . Area Pit or Grout Inspection by Date Final Inspection by P ate a I Additi6not Comments: — ❑ Stk 466-6781 '❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return sit copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED DKK H RECEIVED 9Y DATE PERMIT'N0. .�'EH 13-24 MEV.10/831 opo Y137 37 a 1� �l ZT'-'a"�'� �'�-I`J'417 EH 14-28 I`� ` _f 1 _ f