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APPLICATION FOR PERMIT 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKYON' CA Telephone (209) 466-6781 a PERMIT EXPIRES1 YEAR FROM DATE ISSUED'! y (Complete in`Tripli " -+ Application is hereby made to the San Jcate) aquinf Local Health District for a permit to construct an installs made in compliance with San Joaquin County Ordinance No, JI work h n described escr h. _ 'Local Health District. : ;: _ 549 for sewage or No. 1862 for well and the Ryles and Regulations l0' the work herein described. Tris application is of the San Joaquin Job Address sQ Quin � Y, Y 10 _ s r t.J RLot Size x,. ""' f City �> Owner's"Name PM _ Address- �.- dL Contractor ,� " lc7 3�. Phone ' TYPE OF WELL/PUMP: Address. 7 a y^ �� y r NEW WELL ❑„ License No Phone — 6� T�PUMP INSTALLATION ❑ WELL REPLACEMENT ❑ DISTANCE -0 NEAREST; SEP7lC TANK SYSTEM REPAIR ❑ DESTRUCTION ❑ ��SEWER LINES OTHER ❑ "w.FOUNDATION f -- DISPOSAL FLD. PROP. LINE INTENDED USE ~� AGRICULTURE WELL TYPE OF"WELL PROBLEM AREA OTHER WELLS p{T5/SUMPS ❑ Industrial ❑ Open Bottom CONSTRUCTION SPECIFICATIONS ❑ Domes Private ❑ Man eco Dia. of Well Excavation ❑ Gravel Pack p Tracy T Dia. of Well Casing I ❑ public' 11 Other - Type of Casing ❑ Irrigation J❑ Delta Depth of-Grout Sea], Specifications ; Repair Work Done E3 --Approx. Depth ❑ Eastern SurfType of Grout i Type of Pump ace Seal Installed by_ Well Destruction ❑ Well Diameter H.P. State Work Done # .0 Sealing�Material {top 50'1 f hi Depth . y,.� y 1 a TYPE O SEPTIC W RK: Filler Material {Below 501 Q NEW fNSTALLATIOM❑ _ REPAl13JADDITION DESTRUCTION a t ❑ (No septic system permitted if public sewer is Installation will serve: Residence I f `" -.-�Commercial Other available within 200 feet.) Number of living,units.. j a I E ~ Number of bedrooms r Character of soil to a deptFi of 3 feet: SEPTIC TANK t # I � _ ❑ Type/Xfg Water table depth PKG. TREATMENT PLT, pr+ ` Capacity--_ No.:Compartments Distance to nearest: i yyel{�"+. Method of Disposal ,A S �i Foundation property,Line LEACHIN11-LINE -- Nd ; ."& Length of lines. ' Q° I t FILTER BED ❑ Distance to nearest: Total length/size" (J ' I Foundation I I Property Line ! SEEPAGE PITS ❑ Depth SUMPS 1 /O � Size S�XSX,10 a Distance to nearest: >� Wel! /,,O Number DISPOSAL PbNDS ❑ c _ }. Foundation 1 property Line ~� hereby certify that l have prepared this application and that the work will be done in acco dan�e with San Joaquin county ordinances, state laws,rules and regulatiorts of the San Joaquin Local Health District; Home owner or licensed ageht`s signature certifies fhe'fallowin° - L . ' r ws, and employ any pe►son in such manner as to become subject to wor man's compensation laws of California."Contractor's hiring o�sub-contracting signature g 1 certify that in the performance of the work for which this permit is'issued, I shall not certifies the following: certify that in the performance of the woFk for which this permit is issued, i shall em Io tion Laws of California." p y persons subject to workman's compensa- The applicant. all for all uired inspections. Complete drawing on reverse side. F t Ur % f Signed Title: Date: " FOR DEPARTMENT USE ONLY Application Accepted byh Q " Pit or Grout Inspection Date 'v ©© by Area Date�` Final lnspectior-by Addrtiona! Comments , ' +� - Date ❑ Stk 466-6781c,}4 �# T] Lodi 36.9-3621 E3Manteca 823-7104 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,Tracy 83 P.O. Box 2009, Stk., CA 95201 FEE gMOUNT DUE x INFO AMOUNT REMITTED CK# RECEIVED BY { CASH DATE PERMIT"NO, H 13-24(REV.t/651 H 1426 O �