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APPLiCATION FIR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRIC- `601 =. -iAZELTON AVE., STOCK-ON. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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 Addressy sl' City Lot Size PM Owner's Name ��ti'Gz`1 L! s �/ZrV4=T Address Phone Contractor 1CLcs`s✓t� s C g_Z> Address 7 y' .4 D6 License No.4 y74 Phone1- =3 97 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION❑ SYSTEM REPAIR ❑ OTHER Elt A DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DI L FLD. PROP. LINE V ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Un INTENDED USE TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mantec Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack cy Type of Casing Specifications F] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 1 1 Irrigation Appr . Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of ump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence!/Commercial_ Other Number of living units: _I— Number of bedrooms Character of soil to a depth of 3 feet: SA A► b Water table depth SEPTIC TANK ❑ Type/Mfg I =Ai tr )Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property-Line LEACHING LINE CNo. & Length of lines / — V-40 " Total length/size O 2 FILTER BED ❑ Distance to nearest: Well .1-61 r Foundation 2,01 Property Line &_kKn9Z1_ SEEPAGE PITS ('IDepth 121 Size Number SUMPS Pr/Distance to nearest: Well /00 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 ordinahces, 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." The applicant must call for all requi�r'fed inspec'ons. Complete drawing on reverse side. Signed X� (�� Title: C'�" + Date: '"Ly FOR DEPARTMENT USE ONLY Application Accepted by Date v Date — Area Pit or Grout Inspection by Date Final Inspection by Date ��Z 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH +.EH 13-24 IREV. /a 5) EH 14-28