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;4 r u � •a APPLICATION FOR Pf 51!7' J^AOLJ: LOC4E n&LfH 31ST;:CT q i P, 1601 E. MA.ELTO!i AVE.. STOCtT0;1, CA PERMIT NO. 3 ,K Telephone (20Ri 466-6731 DATE ISSUED +a cERMIT EKPiRES 1 YEAR FRIM DATE 155UE6 . (Complete in Tr.Plicate) - .: Application is her^oy made to the San Joaquin Local Health District for a permit to construct and/rr install the work Herein described. This appiicatinn is m<da in compliance witt San Jnrruin Cornty Ordinate No. 549 for sewage or No. 1867 for well/rum^ and the Rules and Regulations of thr San Joaquin Local Hea1M District. Job Address jri _ I�7X j'g/y �'/ ?.SRbdi..tion Name _ — h _Address ) moi+- A Owners Nam! _ r � JFjpr�/J(dst r M�.2/ Pnvne� i+y. z1_. Contractor's Namz ,{aL i. . n.J _ License Ne rhane.&ZJn%.p7_ 1 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION W 3 PUMP INSTALLATIL* (] SYSTEM REPAIR OTHER ❑• •- DISTANCE TO NEAREST: SEPTIC TANK SEWL LIAES _ DISPCSAc no. PROP. LINE FOUNDATION AGRICULTURE WELL _ OTHEP WELL_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Tottom []Manteca Dia. of Well Excavation L..1 Dpniestic/Private Gravel Pack Ci Tracy Dia. of Well CASing _- Public ❑Other Delta - Type of Casing V Irrigation Approx. r Eastern Specifications - Cathodic Prettv:tiun Depth Depth cf Grout Seal Geophysical Type of Grout Other Surface Seal Installed by _ Repair Work Done [] Type of Pump _H.P. State Work Done �].. Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Belo„ 501 �q TYPE-Of SEPTIC WORK: NEW 1NSTALLATiON❑ REPAIR/ADDITION 1 (% septic tank or seepage pitYpl�bteevi if public n 200 fsewer seweris Installation will serve: Residence X Commercial _ Other 5 Number of living units: Number of bedrooms __2._Lot size t Water taole depth Character of soil to a do p ? No. Compartments - 7 '$ try iYs±/Mfg —;Aj&d& 'r_Capacity/ -- 3 SEPTIC IANK 9sl Cethod of Disposal TREATMENT PLT. [jType/Mfg Capacity SASS_ - a J-- Prop'Jrty Line SEWAGE 'YSTEM G, Distance to nearest: Well Foundation DESTRUCTIOiJ_ fn. 6 Length of lines �40 Total length/size p, LEACI1ING L!Y.E Tj- 9 11 Property Line FILTER BED Distance to nearest: Well A_Foundation �Q_ —_ ^ Depth Size _ NVmber SEEPAGE PI--S Ej Property Line _ )3 SUMPS D Distance to nearest: Well Foundation � _DISPCSPL PONDS ❑ ; 4 I h.+reby certify that. 1 have prepared this application and that the work will be done in accordance with San Joaquin county prdir antes. stale laws, and rules and regulations of the San.Joaquin Local Health District. Hone owner or licensed a agent's esignature certicertifies s suei�he ernnall nernas to bectome sdbJntstohuarkmmms con"ensatieue pe,f,n,nce of the wlawsfof•Ca11f-California permit is iLsoed, ->- Contra tow's hi ng or sub-contracting sl gnature certifies the fallowing: "I certify that in the Performance of the work for which this permit is sauetl, 1 shall MPioY persons '-object to workman's compensation laws of California." an reverse side. / = IDS app:fcen call f all re t d i ti ns. Compl te�rjlSl PO Date: Title: V[4' . Signed C O^ DEPARTMExT USE ONLY Area _ 'MQtk 466-E781 Application '.:c acted Y i`^-[. �-.— Lodi ' 369-3621 Additional Comments: -Date Manteca 823-7104 '4 Pit or Grout Inspection — Tracy 835-6385 '(. f� ( n n.ir�/ Date Final Inspection by P.O. Box 2009, Stk., CA 95291 Applicant - Return all espies to: Environmental Health Penni t/Services 3601 E. Hat ton Ave., M RECEIVED BY DATE PERMIT NO. IFEE BASE AMOLTIT DUE AMOUNT REMITTED - o- 1011V� �� L7 SNfO I q� g_ ,LA. ; 'z 10182 50 EN 13-24 NEV. 10182 14-26 v,