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Ip <br /> i. <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL`-HEALTH DISTRICT <br /> 1601 E. HAZEL T"�O"NA'V.E.,..S'TOCKTON, CA <br /> 1R Telephc6e (209) 4667-081 <br /> PERMIT EXPIRES'l'YEAR'FROM' DATE'ISSUEUn et <br /> (Complete in�Triplicate <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 Ryles and Regulations of the San Joaquin <br /> .Local Health District. <br /> )V <br /> F, P <br /> Job Address CitV7 Lot ;te rM <br /> C <br /> Owner's Name ANC�ZOM A Address ftyn <br /> Phone <br /> A 4 "No. 14aC)g��2 Phone 9 <br /> Contractor W-1ht,-Tj�1aJ.Uddress 25�50 V*1 C-L ftZ1y_t_y__ticense <br /> TYPE OF WELL/PUMP: NEW WELL 13 WELL REPLACEMENT Ll DESTRUCTION El <br /> PUMP INSTALLATION ED SYSTEM REPAIR 0 OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FLD._ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial 1:1 Open Bottom El Manteca Dia, of Well Excavation Dia. of Well Casing <br /> E1 Domesticl Private 1-1 Gravel Pa"Ck 0 Tracy Type of Casing Specifications <br /> D PublicEl Other 1� 0 Delta Depth of Grout Sea] Type of Grout Q) <br /> E:1 Irrigation <br /> ___App rox. Depth Ll Eastern SurfSealing Maferial (top 501ace Seal Installed by <br /> ,Repair Work bone Pump Type of H.P. State Work Done... <br /> Well Destruction 11 Well Diameter <br /> ti I Depth Filter Material (Below 501 <br /> 'T <br /> TYPE OFSEPTICWORK: NEW INSTALLATION ❑El REPAIR/ADDITION Z;;FE'STRUCTION ❑0 (No septic system permitted if public sewer is to <br /> available within 200 feet.) <br /> 4- <br /> Installation Will serve:. Residente At__C_11mercial Other <br /> Number'of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet. Water'table depth <br /> SEPTIC TANK ❑Ll Type/Mig Ca P�acitv No. Compartments <br /> PKG. TRE�ATM� ENT PLT. 1_1� Method of Disposal <br /> +,y)) Cbistancei,to nearest: 1A Foundation JW Property Line <br /> 4;0 t—(7 Pi <br /> LEACHING.-LINE C4 & Length of linessize <br /> ) <br /> I , 11 — Total lengthZ <br /> FILTER BED C1 Disfance-to nearest: Well <br /> I Foundation Property Line Z 4� <br /> SEEPAGE'PITS 0 Depth Number <br /> i • <br /> SUMPS 4 0 Distance o to nearest- Well Foundation Property Line <br /> DISPOSAL PONDS 1 0 <br /> I hereby certify that I have,prepared-this_60-01icati6n arid'thait.tke­—Work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules andregulationsof the San Joaquin Local H,eaith�Ois_trict,' <br /> Home owner or licensed agent's signat6re-certifi6s the.folloVving:.'I ceRlfyffiaitri-f <br /> llTe—perf6rffidffc�e—of-tWwork for which this permit is issued, I shall not <br /> employ person in such manner as to becdmelsubiect toworkman's compensation laws of California." Contractor's hiring or sub-contracting signature f <br /> certifies e 'Ilowing:"Ic 'fythat int.he perfor TLance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion 11 wsof 'fornia. <br /> The ric'n't, u all for all qui d ins ions fete drawing-ofi reverse side. <br /> I - .— Ii - . drawing" k- - . -- - _;.. - <br /> --S iTrfe-d Tifle: hC-a S_ <br /> Date: <br /> JI <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> --Additional-Comments: <br /> D Stk 466-6781 0 Lodi 369-3621 0 Manteca' '823-4104 ,❑O;Tiacy 8�5-6385 <br /> + <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box'2009, Stk., CA 65201 <br /> FEECK <br /> INFO AMOUNT DUE 9)AMOUNT REMITTED -CASK RECEIVED BY DATE PERMIT"NO. <br /> +EH 13'24 E IREV.1 8!5) <br /> H I4-26 <br />