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; .y APPLICATION FOR PERMITy '" = ! j SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELiON AVE., STOCKTO[V, CA � Tele hone (2091 466-6781 s� 7I . P PERMIT EXPIRES 4 YEAR FROM DATE ISSUED [`+ ' (Complete in Triplicate) ri`}�fiszut�tfivy;lTA1C i �Cti 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 I Local Health District. 9 �� Job Address 0� / -w �� City Lot Size PM Owner's Name ±�� { Address q f �r �7 Phone Contract o Address L10 Gpa'%!�;c3) License No. .7- Phone -� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ` PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ i 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 CONSTRUCTION SPECIFICATIONS f i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f (l Public ] Other # Cl Delta Depth of Grout Seal 'Type of Grout I I Irrigation _ _Approx. Depth l I Eastern Surface Seal Installed by r _ { 1 { Repair Work Done ❑ Type of Pump ,Qsd�� H.P: O'er-Q-� State Work Done Well Destruction ❑ Weil Diameter _Seating Material {top%50'i '` E Depth i I _ _ Filler Material..(.Below 50'1 - —._ TYPE OF'SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public Sewer is 1 available within 200 feet.l Installation will serve: Residence— Commercial — .Other fNumber of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No.11 Compartments PKG. TREATMENT PLT. 1, `" Method of Disposal Distance to nearest: Well Foundation _ Property Line LEACHING LINE ❑ No. & Length of lines ----'� Tota! length/size FILTER BED ❑ Distance iito nearest: Welt Foundation Property Line SEEPAGE PITS 11 Depth I Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I I hereby certify that I have prepared this:application and that the work will be done in accordance with San Joaquin'c_ounty ordinances, state laws, and rules and regulations of the San Joaquiri Local Health D%tdct. Home owner or licensed agent's signatuth ore certifies the following: "I certify that in the performance of rfcr-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." s The applicant must 9qII for all re�uir d inspections. Complete drawing on r verse side. p p Signed X Title: Data: r FORD ARTMENT USE ONLY Application Accepted opted by Date 4 Area -/./I r.r Pit or Grout Inspection by Date_ Final Inspection by9 Zdt&&Z e Additional Comments: IR11 ,4 ❑ Stk 466-6781 © Lodi 369-341 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 INFO AMOUNT DUE �t AMOUNT REMITTED CK 41 ASH RECEIVED BY DATE ,PERMIT"NO, +.EH 13-24(REV.1/n 5) J _ 9�/ b� C��r EH 14-28 �J 4,