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1%..� APPLICATION FOR PERMIT � 1. SAN JOAQUIN LOCAL H r TRICT � ' 1601 E. HAZELION AVE., STO W. A Telephone (209) 466-67a) # —/�— PERMIT EXPIRES 1 YEAR FROM DATI€ ISSUED (Complete in Triplicate) ;;e.Application is hereby made to the San Joaquin Local Health District for a permit to construe err /or install thew Ms. plication is made in compliance with San Joaquin County Ordinance No. 509 for sewage or No. 1862 for well% n auonof the San Joaquin Local Health District. 2/ c I'C Job Address 1 33(Q S AML �.. City ftk ^'"Lot Size PM Owner's Name 1j J" tr/.pc—, V_ &R-- A1ddress 1JOK/ J zpryv .cc)��„/ra f/�V Phone Contractor ✓ Address_rna? SAI N 'VV" License No 0 Phone 7 TYPE OF WELL/PUMP: NEW WELL n WELL REPLACEMENT n DESTRUCTION n PUMP INSTALLATION W. SYSTEM REPAIR 0 OTHER O 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 0 Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing XDomestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications FI Public n Other FT Delta Depth of Grout Seal Type of Grout_ _ �1 I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by T _ Repair Work Done ' Type of Pump S J '? H.P. 3 State Work Done-TA Well Destruction n Well Diameter Sealing Material Itop 501 ! Depth Filler Material (Below 501 "1 TYPE OF SEPTIC WORK: NEW INSTALLATION I-I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: - Water table depth d SEPTIC TANK 0 Type/Mfg Capacity r No. Compartments PKG. TREATMENT PLT.❑ , 'd (- ; TyMethod of Disposal Distance to nearest: Well :Foundation—.-rte_ P 0paryy.Line .._ ,. ri�DiVlt;�r r, LEACHING LINE n No. a Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 I hereby certify that I 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. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for 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-con!racting 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." The applicant all for all req d ins p ns. Complete drawing onreverseside. �)� /� Signed X L].�CiJr�+ r Title: ( O– – Date: d/L� 17� FOR DEPARTMENT USE ONLY Application Accepted by Data Ar Pit or Grout Inspection by Date Final Inspection by ate Additional Comments: 0 Stk 466-6761 0 Lodi 369-3621 0 Manteca 623.7104 0 Tracy 835.6365 A�ppplicaa}nntt - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 \11XV INFO FEE AMOUNT DUE AMOUNT REMITTED �/A/�SH EKED BY DATE PERMIi'NO. . EM 13.24 I .v n 5J �� I q56 EM 1bM