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i� APPLICATION FOR PEzn'T SAN JOAOUiN LOCAL HEALTH DISTRICT PERMIT 40.513 O 1601 E Telephone N(209)'466-6781 AVE N CA GATE ISSUED 7j �. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in.Triplicate) Application is hereby awde to toe` n Joaquin Local Health District for a permit Co construct and/or So or l the work hereto Applicata This application is eede in compliance with San Joaquin County Ordinance No. 549 for sewadescribedge or No. 1862 for welt/Waw and the Rules and Regulations of the San Joaouirk LocalHealth District. ld/ r� w%QT/� g1PLu 4,0Subdivision Nome Jab Address 7 ) /Q�^y y��y sQ/Arr_.Q Phone - i, �iL b Address Phone Owner's Name - 7 rr Q2 /2 License No. Contractor's Nam --I DESTRUCTION ,\ W nM sw❑.r__,'WELL REPLACEMENT ❑ ❑_ \� \y TYPE OF WELL/PUMP WORK: �b-art NEN WELL OTHER RUMP,14STPIiLAT7-0N Q_SYS .REPAIR] ❑ U 1 NSRER LiNEc-4` 1 DISPOSAL FLO. PROP. LINE DISTANCE TD NEAREST: SEPTIC TANK •>T ' 's AGRICULTURE WELL-C"`+- OTHER WELL PITS/SUMPS (7 FOUNDATION INTENDED USE TYPE OF WELL PRUBLEM AREA � CONSTRUCT4PECIfIUTIOIS Dl:. ofiwelli Eacava£ibn— U Mantas - ❑ Industrial ❑Gravel Pack open Bottom ❑ ❑Domestic/Private , ❑Tracy Di . of We}1 "Casing nPubt is �.�.-0ther.. `` []Delta Type of Casing U Irrigation Approx. ❑Easterr ( Specificatfons I ❑fAthgdSt Protection Drptn a. - Depth of Grouf Seal .E �' . ❑Geophys icai Type of Grout". — I ❑other Surface Seal installed by _ -- s �' H.P. ^._State.Nork'Done Repair Work OoneiD.Type cf. A r i >4 _ Sealing Material (too 50') I Well Destruction [J Well Diameter Filler Material '(BelOw 50') Si Depth _- t .- >•— - .. •� TYPE OF SEPTIC WORK: NEW INSTALLATION f REPAIR/ADDITION ❑ (NO septic ti seepage Pit vai�lableewithiif nu200 feet) is Instal lationy^Vis: serw: dResid,ence !/ Coimrrcial Other Number of lav Ing unf't�ff�Number_o f-bedroars-.. _3 . . LoMize r�;i �l" _ 09 Water Kahle depth .� Character of soil to a depth of 3 feet: No. Compartments .) y Capacity SEPTIC TANK r) TYpe/Mfg Capacity Method of Disposal p/•,D_ TREATMENT PLT. ❑ Type/Mfg ? -- Ii FoundationT Drop¢rty Line SEWAGE SYSTEM ❑ Distance to nearest: Well - DESTRUCTION __�{ To tat length/size LEACHING LINE ❑ No. 'B�Le�th of El toes Property Line =•FDwtldtion FILTER BED [�.- Distance to nearest: Well _ _ Depth _ Sire Number f SEEPAGE PITS f,% ❑ puna on Property Line SUMPS L) Distance to nearest: We DISPOSAL PDNOS ❑ done I hereby renceserstatet at I anderulesaand regulations agf then Sannat Joaquin Localwork sll Health Districtccordante with San Joawork for county Home owner or ate laws agent's signature certifies the following' "i certify that in the performance of the work for Calif this in-t1Po'.perfomrtanZRro! the work for which permit is issued, t snail not employ any penin to such manner as to become subject to>workrenY compensation laws of work California." Contractor's hiring or sub-contracting signature certifies the following: "I on laws of Ca this permit is issued. I shall employ persons subject to workman's compensation laws of CalifortiSTa." The applicant must cell r a uir nsnec tions. complete drawing On reverse side. Date: ffA�- ;7 Title: Signed % ;1 F DEPARTMENT USE ONLY _ Area to C] Stk 466-6781 Application Accepted by` ❑ Lodi 369-3621 Additional Co nts: Mate t?E�Zdanteca 923-7104 Pit or Grout Inspection by ��r/--{��-�7_ a Tracy 835-6385 1 - nl� _Date —Y'"�- CA 95201 Final Inspection by Applicant - Return all copies to: Er vlronmen tat lth Permit/Services 1601 E. Hazelton Ave., P.O. Boa 2009, Stk., RECEIVED By DATE PERMIT N0. FEE BASE AMOUNT DUE AMOUNT REN ITT ED q --y -I-INFO' , 1 Qom\f 10/82 500 i EH 13-24 REV. 10182 14-26