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_ APPLICATION FOR 13ERMIT _ R ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—i ON AVE., S OCKTON, CA Telephone (209) 781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' (Complete in Tripli ate} Application is hereby made to the San Joaquin Local Health District for a permit to c nstruct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 11162 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. Job Address —� Ci �faG�7�� Lot Size PM " J Owner's Name Crvr+ Address A Ffione k Contractor Address_ License No, Phone TYPE OF WELL/PUMP: NEW WELL Jg WELL REPLACEN ENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ _ y SYSTEM REPAIR.❑_ _ _ _ OTHER wells 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 CONSTRUC ION SPECIFICATIONS ❑ Industrial i ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private X Gravel Pack ❑ Tracy Type of Casir Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 2.SType of Grout ❑ Irrigation 70__�Approx. Depth ❑ Eastern Surface Seal nstalled by f Repair Work Done ❑ Type of Pump _. H.P. . State Work Done Well Destruction ❑ Well Diameter Sealing Material ("top '1G Q O MP.dj'foIei� Suj�1LT Depth Filler Material (Below ,} TYPE OF EPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is s available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ? Number of living units: Number of bedrooms I' Character of soil to a depth of 3 feet: ' Water table depth SEPTIC TANK ❑ Type/Mfg Capa , No. Compartments PKG.TREATMENT PLT.❑ ' J Method of Disposal Y Distance to nearest: Well Foundation Property Line T l LEACHING LINE ❑ No.& Length of lines Total length/size - FILTER BED ❑ . Distancelto nearest: Well Foundation •Property Line SEEPAGE PITS ❑ Depth '° Size Number SUMPS �. : ❑ distance to nearest: ' Well Foundation Property Line _ 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 111 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 compensationlaws of Califomia."Contractors 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." The appli n ust call fo 11 r uired in ections.-Complete drawing reverse'si a""- Signed Ti : C C. Date: FOR DEPARTMENT U SE ONLY , Application Accepted by — Date — Area Pit or Grout Inspection b Date Final Inspection`b Date 2:;.? S_ Additional Comments: ❑ Stk 4664MI ❑ Lodi 369-3521 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant-'Return all copies to: Environmental Health Parrrit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO y + EH 1324{REV.V85) i 3 O �ti� � as lia-S-1 EH 74-78