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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601EHAZE' N.AVE., ST.00KTON, CA Telephone(209) 466-G781 .epho 6 1 PERMIT EXPIRES 1 YEAR:FROM DATE'ISSUED 4 �t_ { iCompiete in Triplicate} t This application is permit to construct and/or install the work herein described• and,the Rules and Regulations of the San Joaquin ` e with San Joaquin County Ordinance No.549 for-sewage or No.1$62 for welllpump Application is hereby made to the San Joaquin Local Health District for a pe s .O made in compliant i - .,3 , 1 i { . Local Health District. rozf:,. „ ,, fxfN [ r#fp PM I. Lot Size - Ct cr . . City Jab Address i.- - i = -- ' _ one Pfi .� Address - -Owner's Name phone�� - �-- License No. Address DESTRUCTION ❑ y Contractor WELL REPLACEMENT .O NEW WELL ❑,,` -t ,.-»-. .OTHER".❑ ".. , i - TYPE OF WELL/PUMP: _.,, -r •-SYSTEM REPAIR,❑""" PROP. LINE PUMP INSTALLATION"❑ SEWER LINES DISPOSAL FLD. 0T4fER WELL PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK AGfiICUt E WELL k. FOUNDATION �— TYPE OF WELL . PROBLEM EA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing INTENDED USE ij ❑ Ma eca Dia. of Well Excavation ❑ Open Bottom•'" specifications ^t D Industrial Type of Casing + Typo of Grout 1�► r ❑ Gravel Pack+ ❑ , racy t ❑ Domestic/Private Delta Depth of Grout Seal { yy 1 c ❑ Public ^" ❑ Other V` ' ---Approx. De ❑ Eastern Surface Seal Installed by'"�� G ❑ irrigation H P 'r r State Work Done."• Repair Work Done ;❑ Type of Pu r y i Sealing`Material (top 50')x,= Well Destruction ❑ #Well Di ' eter .T— Filler Material (Below�a0') t Depth : > available within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted'rf public sewer[s \ y t ✓ I Installation will serve: Residence L Commercial— Other r Number of bedrooms ' �' s Number of living units:- -4— i "" '` Water table depth [ Character of soil to a depth of 3 feet: ` ' No. Compartments ❑ Type/Mfg capacity- 0 SEPTIC TANK 1T °,; t Method of Disposal PKG. TREATMENT PLT. O , •Pro a Line C Distance to nearest Well Fobndation P rtY 'a ' _ t l ' 7atal length/size - LEACHING LINE ❑ No. & Length of lines i FILTER BED �. ❑ Distance to nearest: 4 -Well 1 fi Foundation µ Property Line SEEPAGE PITS ElDepth _Size 3 T — V Number "' d" Foundation — Property Line. SUMPS ❑ Distance to nearest: Well_ n F; I DISPOSAL PONDS ❑ 1 i a 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. - -' ` t . 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 parson in such manner as to become subject to workman's compensation laws of California.,' 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." si M The applicant must call for all required inspections. Complete drawing on reverse side. Title: Date: Signed X w Oil✓ ,FOR DEPARTMENT USE ONLY . r� Area Application Accepted by Date L�, ' A Pit or Grout Inspection by Date $ Final Inspection by` � Dated Cr'1 Additional Comments: V Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 8356385 Y Applicant- Return all copies ta: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 - 3 FEE INFO AMOUNT DUE AMOUNT REMITTED CCAKSH RECEIVED BY DATE PERMIT.NO. b 2 i _ 2Z + EH 13-4(REV.t�a 5} EH 14-29 4.