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APPLICATION.FOR PERMIT SA'N JOAQUIN LOCAL HEALTH-DISTRICT 1601,E. HAZELiON AVE., STC)CKTON, GA a Telephone (209)466-6781. PERMIT"EXPIRES.i YEAR FROM DATE ISSUED` (Complete.in Triplicate) s it AWP=s on is hereby made to.the San Joaquin Local Health District for a permlt.to ns and/or install tRe work tereln descrtpati This appfieation made in.compAance with San Joaquin County Ordinance No.5413 for sewage of No.1862.for well/pump and the Rules and Regula"of the-San Joaquin" Local health District. Jobi4ddress j Cir/ Lvt'SL-e�L PNi Owner's Narre Address (- A Phone ! contractors Name --- license No. Phone q TYPE OF WEI.LIPUMP. NEW WELL.u WELL REPLACEMENT`O DESTRUCT"tON'O v i PUMP INSTALLATION ❑ SYSTEM REP41R ❑ ", OTHER'i1 DISTANCF TO NEAREST. SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.LINE F=UNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS. INTENDEDUSE . TYPE OF WELL" PROBLEU[AREA. CONSTRt]C7iON:SPECIFICATIONS ' ❑lndusuial ❑Open-Bottom D Manteca Dia_of Weil Excavtion Dia.of Wall.Casing - '0 Domestic/Private .❑Gravel Pack 0 Tracy Type of Cd3ing Specifications '- 4' G Public Q Other 0 pelta, Depth.of Grout Seal Type of Grout ' «r ❑irrigation —A� h 0 Eastern Surface Seal installed by _ cf . 3 , .x.Depth Repair Work Done 0 Type of Pump H.P. Sure WorK Done F - Wen Destruction C3 Weg Diameter _—.-- Sealing Material(top,507. Depth Filter Material(Below 50') " I. TYPE OF sep-nc WORK: NEW INSTAr-LATION❑_,REPAiR/AODITION DESTRUCTiGN [} (No septic system permitted rf public is. • available within 200 fast.) .i Irtn.3tiation win serve:. Residence Corcmerc�f Other I3urttber of Irving units: Number of bed'. character of sod to a depth of 3 feet._r1. Water tabic.depth ` j SEPTIC TANK 0 Type/Mfg Capacity No. Compartments _ s PKG.TREATMENT PLT.0 ' .Method of Disposal Distance to nearest: 1Nen Foundation Property Lane._'_ - i�s LEACHING LING No.A Length of Ines 14 Total length/size a FILTER BED [7 Distance to nearest: We.: oundation Property Line ,SEEPAGE PITS Cl. Depth $i�e'�_ __ Number. SUMPS C] V tour*to nea:ast: Well Foundation_ Property Line DISPOSAL PONDS' ❑ 7i F r #- 1 hereby certify that i have prepared this application and a+et the work wlll be done in accordance with San Joaquin county ontinances,state laws,and ';. rules and regulations of the San Joaquin West Health District. s Homo.owner or ficensed agent's signature certifies the following:"I certify thaE in the performance of the work for which this permit is Icwed,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-contrs6ting signature < certifies the following,1 certify that in the perform nce of the work for which this permit Is Issued,I shalt employ persons subject to workman's compensa- i tion laws of California." The.applicant n for all.rregt,rre�E attione Complete drawing on reverse aide. 5igLj nod `" Title:, a;t`�Kf'� — --Data. T zrtl✓' �. �� 4 FOR DEP AR {NT USE ONLY - Appfxxtion Accepted by 4yDate .` .1ree p� Ps;or Grout Inspection by r`" Da"; Final Inzpecdon by Date S G y Additional Comments: E'Stk 466.Ml ❑Led 35911MI ❑Manteca ffi37104 Ll Trncy 835-6385 Applicant-Rewm all co01.TO: Fmircnmental Health Pernit/Services 1601 E.Ha2Rlton Ave., P.O. Box 2009,Stk.,CA 952131 IFEE NFO AMOUNT DUE AMC,UNT REMITTED C Ii RECEIVED BY DATE PERMIT NO do O