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Ic APPLICATION FOR PERMIT O� �a � SAN JOAQUIN LOCAL HEALTH DISI RICT � 1601 E. IIAZELTON AVE., STUCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' (Complete in Triplicate) Application is hereby made Co the San Joequin Local H 4h District for a permit to construct and/or install the work herein described.This application is J made in compliance with San Joaquin County Ordinance No.549 for sewage or No. x862 fr.r.yell/pump and the Rules and RggulalSozis of the San Joaquin Local Health District. Q � Job Address __-�_V I 00 I ✓C Owner's Name �0 V1n s Like _ L�{IAddress ._ 3�_Lt] (j�t111 Phone �7- 1rU Contractor.—LlILC_ffX�_____Address ________Same _ -License No. __Phune TYPE OF WELL/PUMP: NEW WELL FI WELL REPLACEMENT 1'1 DESTRUCTION O PUMP INSTALLATION 1, SYSTEM REPAIR [I OTHER O {� l DISTANCE.TO NEAREST: SEPTIC TANK. _—_ SEWER LINES DISPOSAL FLO.- PROP. LINE \�1 ` FOUNDATION AGRICULTURE WELL __ OTHER WELL _ PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑Industrial O Open Bottom ❑Manteca Dia. of Well Excavation Die.of Well Casing _ (� El Domestic/Private ❑Gravel Pack L-1 Tracy Type of Casing Specifications O Public IJ Other C 1 Delta Depth of Grout Seal __ Type of Grout ❑Irrigation ---Approx. Depth I I Eastern Surface Seal Installed by_ } Repair Work Done 1.1 Type of Fump H.P. _____--__._____-. _ State Work Done Well Destructi n C7 Well Diameter - Sealing Material Itop 501 Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION RFPAIR/ADDITION[1 DESTRUCTION (No septic system permitted if public sower is available within 200 feet.) Installation will serve: Residence K Commercial--_ Other, M' H Number of living units: _/-_ Number of bedrooms 19-.___ �n , Character of so°I to a depth of 3 feet: --gall cc_--._ _ ___._____.___-_._..__.._-___Water table depth-60 SEPTIC TANK I?{Type/Mfg 5 �-_._.--___...__.-_ Capacity__.�o2 Q0._ No. Companmonts _� PKG. TREATMENT PLT.i i , Method of Disposal _ DLtance to nearest: S all 77 / _ .r`�O _ Foundation r_ Property Line ------------ LEACHING UNE >c No. 8 Length of Imes ..__ (] _- Tota __ l length/size___ [�.�— FILTER BED i; Distance to nearr at: Well.>(�ZQ.. Foundation lQ_ Property Line � �� SEEPAGE PITS Ci Depth -_�QSiza ___.ff _ 1.-_xlQ _ _ . Nurnber__ !— SUMPS f.•. Distance to nearest: Wn11I,200 Foundation 1>/001___ Property Line >_ DISPOSAL PONDS 11 _ 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 Lot.al Health District. Horns owner or licensed agent's rigoature certdios the following: "I cornlly that in the performance of the work for which this permit is issued,1 shall not employ any person in such mannan its to become subject to workman'&rornlensauon laws of California.-Cvntractor s niring or sub-contracting signature canities the following:•1 certify that in the performance of the work for witch this permit is issued,I shall employ persons subject to workman's compens i- tion laws of California." The applicant m ist call for all regyked inspections. Cornplete drawing on reverse side. Stgnedx,K0n C_.- ------ - - TIlo. --- -UWi1V' ---- n:•t�. s-- /�-87 FOR DEPARTMENT USE ONLY `n�fr Q /1 Application A: zpted by --- -- �L `�_..-_ ___.__ _____.___. Date_ / _v Area v v Pit r :-out Inspection by ___��1A.---- -- Date -._ Final Inspection by-� rJ Dat, 543-97 Additional Comments: G Sik 1666781 Ll Lodi 3693621 i. Manteca 823 7104 1 1 Tracy 835 386 Applicant- Return all copies to: Environmental Health Parnut/Services 1601 E Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE INTO AMOUNT DUE AMOUNT REMI'TEDr+a� RECEIVED ay DATE PERMIT NO. rc. H:4)24ie(v i /Q ._ O, _r:•(S', I - / i •.vC�� EH