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I' APPLICATION FOR PERMIT . SAN JOAQUIN LOCALAITO PMICHEALTHSERVRCBS I� 1601 E. HAZELTON AVEMOftEWALHBALTHDMSION Telephone (209) A66-67$1� �� PERMIT MI*� ; PERMIT EXPIRES 1 YEAR FROM D (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. J1 !< Job Address r�� City Y1 /VKV Lot Size PM Owner's Name I1J I Tt C U Address 13 Z b (� • b-)Z AFF / Phone qy$- (Contractor G�� 11 L1ldGAddress D 'DOW.,-J"A-v�License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ( ,l PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERJ. Y1"1S� {�VXJC�CJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE Ij FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ; INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /r Industrial ❑ Open Bottom CI Manteca Dia. of Well Excavation r 'I 1 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing _�` S/►�(, PUS Specifications I F] Public '6th r f-] Delta Depth of Grout Seal G44ype of Grout ___. ...—._. 1 1 Irrigation pprox. Depth I ) Easterrl Surface Seal Installed by Al. S r'�N��G lq{. State or&k Done _ Repair Work Done ❑ Type of Pump P. Well Destruction ❑ Well Diameter _. �� Sealing Material (top 50') _ Depth () '-56 Filler Material (Below 501 — W TYPE OF SEPTIC WORK: NEW INSTALLATION { 1 REPAIR/ADDITION I I DESTRUCTION 1 I (No septic systern permitted if public sewer is ,) n available within 200 feet.l 41 I Installation will serve: Residence____ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments yPKG. TREATME=NT PLT. Q Method of Disposal IE11 Distance to nearest: Wel{ Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1+ ik 'SEEPAGE PITS l I Depth Size Number ;SUMPS 0 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 irules 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, 1 shall employ p&soris subject to workman's compensa- ;tion laws of California." l'The applicant s call for all required inspections. Complete drawing on raver side. / (;Signed X �'"`W Title: �t 5, /vvA Date: d F R QEPARTMENT USE ONLY Application Accepted by Date ( v Are J r � :Pit or Grout Inspection by 7 Date 3� � y Final Inspection by Date Additional Comments: VV ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 jApplicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO �.EH113.24IREV.r/n5l 0-7-S7 EH 14-26O i !S