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I I APPLICATION FOR PERMIT SAN JO.AQUIN LOCAL HEALTH DISTRICT 1601 E. HA7ELTUN AVL . STC^KTON, CA Telephone (209)466-6761 PERMIT EXPIRES 7 YECR FROM DATE ISSUED iComplete in TpipiiDRte) 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 made In compliance with San Joaquin County Ordit ante No.539 for sewage or No.IM for well/pump and the Rules and Regulations of the San Joaquin t Local Health District. C 9 r-` Job Address Lt 7 `LZ Lam,—les^``^� 'R=— City- I Lot Size y'�-4es ' .,Pm J" Owner's Name Address .—�Lt ' Z-7- Phune -]—!!-1-J-- Contractors Name a f =- License No. Phone TYPE OF WELL/PUMP: NEW WELL Li WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.__ PROP ONE ..— FOUNDATION AGRICULTURE WELL OTHER WELL__._ F_' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑Intlustrial ❑Open Bottom ❑ Manteca Dia.of Wall Ezcavetion Dia.of Well Cawog ❑ Domestic/Private ❑ Gravel Pack C Tracy Type of Casing____— Specifications o' I a �:�. GAA ' r 11 C Public ❑Other ❑ Delta Depth of Gre„ `" 1 Type al Grout ❑ Irrigation _ Approx. Depth ❑ Eastern Surface Seel Installed by ne Repair Work Do ❑ T.ype of Pump H.F. S ate Work Don } ell Destruction 'G� Well Diameter Sealing Material(top 50'1 W Depth__ Filler Material(Below 501 J TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION C DESTRUCTION F (No septic system permitted if public sewer is IInstallation will serve: Residence_ Commercial_ nther available within 2011/sel) Number of riving units:_ Number of bedrooms Character of so;l to a depth of 3 feet: --Water table depth_ SEPTIC TANK C Type/Mfg — Capacity_—. No.Compartments — PKG. TREATMENT PLT.C Method of Disposal Distance to nearest: Well_=Foundation_ Property Line = 1 LEACHING LINE ❑ No. 8 Length of lines _ Total length/size— FILTER ength/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑7c'�Depth Sue Number SUMPS iTDistance to nearest: N all Foundation Property Line DISPOSAL PONOS ❑ __ I hereby certify tial I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws, and ck rules and regulations of the San Joaquin Local Heakh District. I shall not Home owner or licensed agent's signature certifies the following: "I certify that's:he performance of the work for which this permit is issued, employ any person n such manner as to become subiert:o wurkman's comrmsation laws of California."Contractor's hiring or sub-contracting signature certifies the colo wirg:"I certify that m the performance of the work to, this permit is issued,I shalt employ persons subject to workman's companies. tion Jews of California." The applicant mus call for all requ;ireptins,ecitionti. Complete drawing on reverse side. /`�q�J � Signed11h _ Title: C-d--»nn Pte- _ Deter _�=t`� k OR DEPARTMENT USE ONLY 11 Application Accepted by oQ n. — Date J 7�J- � Area Date Final Insperl by IGH Date 13 D j Pi[Or Grout inspection by Gn/// r Additional Comments: -- ❑ Stk 3666781 Lodi 369-3621 L: Manteca 823-7104 ❑Tracy 63F6386 Applicant- Return al:copies to: Environmental Heal•h Permit/Services 1601 E. Haemo,Ave., P.O. Bos 2009, Stk., CA 957.01 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIV EO By DATE53 � EPMIY NO. N NFO 3 ! ,�_. �-137 ? . FN 11M iRFV 10'Wr ��- � FN uA