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r _ } APPLICATION FOR PERMIT �� SAN JOAQUIN LOCAL HEALTH DISTRICT STOCK ELTION AV ` TON-" No ".P"""7° 1601 E. HAe ephone 2091 466-6781CA AYEAR FROM DATE PERMIT EXPIRES 1 ISSUED (Complete in Triplicate? lication is fand the Rules and Regulations of the San Joaquin f f e or No. 1862 for ell is hereby made to the San Joaquin Local Hee lth 5is for for ag permit to construct ell pu install the work herein described. s aPP.. Application Joaquin County Ordinance made.in compliance with San PM I ` Local Health District. Lot Size City �6 a Job Address fan ° Phone 1 Address 14 �� 7732 3 l <Owner's Name V(d RU .—•_Phone - License N pESTCTION ,�' Contractor WELL REPLACEMENT k NEW WELL! !� OTHER ❑ r I TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ PUMP lN5TALLATION- f -+ PROP. LINE SEWER LINES 1_a--- DISPOSAL FLD• PlTS15UMP5 DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL1— FOUNDATION s�-- it �- PRQBL� EM AREA_, CONSTRUCTION SPECIFICATIONS �. ia. of Well Casing INTENDED USE TYPE OF WELL L3 open Bottom ❑ Manteca Dia. of Well Excava ion I '*specifications ❑ Industrial ❑ Tracy Type of Casing , . • Gravel Pack T e of Grout pomesticl Private 5r Depth of Grout Seal ❑ Delta �J ' [`I Public ❑ Other Surface.Seal installed by 1 ' l I lrricJation �.Approx. Depth I 1 Eastern _ State Work one — H.P. _.Repair Work Done ❑ Type of Pump 11 ; We ter Sealing Material (tpp 50'1 Wel! Destruction Pf' _ Filler Material (Below 50'1 f �. ��REpAtR14{)r.�IT�ION 1 1 DESTRUCTION l I aNailablefwithin 200 feetc system ltled if public sewer is TYPE OF SECommercial�PTIC WORK.—NEW�IN!FAL�ATI Other installation ill serve: Residence Number of bedrooms Water table depth Number of living units: Character of soil to a depth of 3 feet: 'Capacity_� No..Compartments SEPTIC TANK ❑ 'Type/Mfg Method of Disposal n PKG. TREATMENT PLT. ❑ Foundation __�.:Property Line Distance to nearest: Well ; _ Q-• Total lengthisize LEACHING LINE Ll' No. & Length of lines Property Line_� Foundation yr ` ,ar FILTER BED ' ❑ Distance to nearest: Well _y y y f Size Nube SEEPAGE PITS ! I Depth Propertymr, Line_�.--- --Foundation�— SUMPS ~` L7 Distance to nearest: Well r DISPOSAL PONDS C7 .� ! hereby certify that l 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.g isubject to workman's compensation laws of California.' otraceo nsrsubjecrt to workman's acting Home owner or licensed agent's signature certifies the following: l certify that in the performance of the work for which ing this psub ermit is issued, I signature steal not employ any person in such manner as to become certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ P f ► tion laws of California." / The applicant t call for all requ ed inspections. Complete drawing an re side. Date: ^` /�Tftle: Signed X FOR DEPARTMENT USE ONLY, D Area Date Application Accepted byDate ate §77Fina! Inspection by rNe!J 0-r vee • Pit r Grout Inspection by � �1 1 Additional Comments: ❑ Additional 46Com ❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy 835- 5 CA 95201 r,w c ft vw v+ett Applicant - Return all copies to: Environmental Heal Permit/Services 1601 E. Hazel on Ave., P.O. Box S k., CA 01d C �+ C RECEIVED By DATE PERM IT•tVO. FEE AMOUNT DUE AMOUNT REMITTED SH �r�- !� INFO Q /� "')fL, + EH 13-24(REV.5ie5) EH 14-28...