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t <br />APPLICATION FOR PERMIT r`= . <br />S N JOAQUIN LOCAL HEALTH DISTRICT <br />1T1 E. HAZE T ON AVE., SOCKTON, CA <br />Telephone (209) 466-6781 - <br />4 <br />PERMIT-EXPIRES EAR FROM DATE ISSUED <br />ICornplete in Triplicate) rZZctGC2Y leD= 4 <br />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 <br />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 <br />Local Health District. <br />Job Address n CityLot Size <br />r <br />Owner's Name C Address F0• SOX 251D &*l^_h C& CN901 Phone qfS 7 <br />ply L_ 1' 510NIZACtrls f3CTI c_a Address <br />7 <br />0?T0ConiractarL3._ Q, KOX ,S L' License No. SIQOD4 Phone <br />TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION <br />PUMP INSTALLATION SYSTEM REPAIR OTHER <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br />I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />Industrial Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing <br />Domestic/Private Gravel Pack Tracy Type of Casing Specifications <br />M Public Other Delta Depth of Grout Seal Type of Grout_ <br />I I Irrigation Approx.{Depth I I Eastern Surface Seal Installed by <br />Repair Work Done Type of Pump H.P. State Work Done_ <br />Wel! Destruction Well Diameter Sealing Material (top 501 <br />Depth Filler Material (Bel w 501) <br />TYPE OF SEPTIC WORK: NEW INSTALLATION. REPAIR)ADDITIONIX DESTRUCTION l I INo septic system permitted if public sewer isfilablewith; i.1 <br />Installation will serve: Residence_ Commercial Other N <br />Number of living units: Number of bedrooms lCharacterofsoiltoadepthof3feet: Water table depth <br />SEPTIC TANK Type/Mf F9' Capacity No. Compartments <br />PKG. TREATMENT PLT. Method of Disposal <br />Distance to nearest: Well Foundation Property Line l <br />f <br />LEACHING LINE No. & Length of li es Total length/size <br />ILTER BE Distance to nearest: Well ou tign Property Line <br />SEEPAGE PITS I I Depth Size Number 1 <br />SUMPS Ll Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS <br />I hereby certify that t have prepared this application and that the work will be dons in accordance with San Joaquin county ordinances, state laws, and <br />rules and regulations of the San Joaquin Local Health District. <br />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 <br />employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signaturecertifiesthefollowing: "!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." I <br />The applicant must call for all required inspections. Complete drawing on reverse side. <br />Signed X L i ate: <br />FOR DEPARTMENT USE ONLY <br />Application Accepted by 4,21/-5Date / of Area <br />Pit or Grout Inspection by ate <br />rrFin <br />alylnspecti on by Date <br />G <br />Additional Comments: ' V S/ !7' 1' /fir Gzd a`srr' <br />E Stk 466-6781 Lodi 369-3621 Manteca 823-7104 13 Tracy 835-6385 <br />i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.-Box 2009, Stk., CA 95201 <br />FEE <br />INFO <br />AMOUNT DUE AM OUjNT REMITTED <br />CASH RECEIVED BY DATE PERMIT NO. <br />EH14-241AEV.t/x51 <br />I L ( lQ 1/0-17 8 <br />EH 14-2t3 <br />1 <br />i