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APPLICATION JOR,PERM!T 3 a3 1 - SRN JOARU itt LOCAL HEALTH OiSTRIC7 PERMIT 90- 1601 E. HA4004AVE., STpCKTON, CA Telephone ( DATE ISSUED 209) 466=6781 „ f . I'+ pERM1T EXPIRES 1 YEAR FROM GATE ISSUED (Complete in Triplicate) `i perm to construct and/or inestoalNthe h1862r for well/Pump ' liance with San Joaquin County Ordinance No. 549 for sewage Application is hereby made to the San Joaquin Local Health District for a p " described. f;This application is made in comp �7�— I• , Subdivision %ame �D/ Phoneme and the Ru l.gs'and Regulation ns of the SZ Joaquin Local Health District. ' �- ', Job Address. 4 AddressIW 2-ZJ_ phone 44-:C- — Owner's Name -� is^n QST LN WOOD __License No• ZS ` Contractor's NameY WELL REPLACEMENT DESTRUCTION OTHER LJ NEW WELL "❑ TYPE OF OF WEASYJTtM REPAIR �. PUMP INSTALLATIONPROP..LINE.�:•• + w» , , �. DCSPOSAL•FLD. ^' PITS/SUMPS ' - VL ww�'�!'SEWER LINES OTHER WELLC*TA �— DISTANCES FOUNDATION SEPTI AGRICULTURE WELL � R CONSTRUCTION SPEC1fICAT IONS II TYPE OF WELL RROBLFW REA ! ' Dia. of Melt Excavat5on INTENDED USE �— `Y)' Dia O Well�C+�g r �� Open Bo'ttad.� (�-Mantec a r ❑industrial Tracy 1 t u pomestic/Private Gravel Pack a,e.F„ e of Casing. •R , t 7 '• [j Other []Delta . YP - i 0 Public m C3 Eastern Specifica.ations Approt ,I Lj Irrig tt0, Q't it, Depth x pepth o{ GroutkSeal.,"%' i II Cathodic Protection TyJpe'faf+Grout P �Geophysi«a^ 4. �:SOrface Seal installed by'�.�---'- G D other ,j 4 ) •State Work'Done RepalraWork gone [J„fTYPe of,cPump H.P. ��^.. -.+� w. (tOP Well Diameter _�Sealing Material(Belo 50' `.-+ - `� Well 01 Destruction ❑ Filler Ma1erAa1 (Below 50') _ _- Depth ++ ubl is sewer is it Permitted if P REP0.I R/ADD iT ION7 yx�I (No septic tank or seepageP available within 200 feet.) I TYPE OF SEPTIC WORK: NEW INSTALLATION � Commercial > r Ot / installation will serve: Residence _ Lot size Number of bedrooms �— y Water table depth Number of living units:- f 3 feet: F�� No. Compartments Character of $011 to a de t� %% Capacity l�{ype/Mfg ' Method of Disposal SEPTIC TANK �-JX�L� "'sr+. Capacity � Line PKG. TREATMENT PIQ.,]y� Type/Mfg - 'Foundation .�_ Property SEWAGE SYSTEM Distance to near'st: Well it DESTRUCTION Tbtel length/size LEACHING LINE a Length of'ii A-es Foundation Property Lfne -- ;, Distance to nearest: Welly I FILTER BED pX L'J Number Depth A a Size lr L — property Li �T� N�� SEEPAGE PITS Foundation QF.L7 Y ffbk Com/ 'SUMPS ❑ of stance to nearest: Well P.Q y Y DISPOSAL PONDS 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 reguleasifies the followingmanner s of the San °to certifin Local yealth District.sthat iin theorkman5 compensation laws of Californil Home owner or licensed agent's signature certifies the following: "I certify that in the performancelof�the work for which this on in suc permit is issued, I shall not employ any p Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the a.,,pernonce of the work for w this permit is issued, I shall employ persons subject to workmen's compensation laws of California.,, The applicant must call for all required inspections. Complete drawing on reverse side. Date: 147 Signed % q/EN�U� _Area` _ Stk 466-6761 1 / FOR DEPA ENT S Y Application Accepted Dy ; Lodi 369-361 Additional Comments: Date Manteca 823-7104 Pit or Grout Inspection Oate (� Tracy 835-6385 Final Inspection by Applicant - Return all cops s to: Envir omental Health Permit/Services 1601 E. H elton Ave., P.O. Box 2009, Stk., LA 95201 rINFO BASE MAMOUNT DUE AMOUNT REMITTED RECEIVED SY _ DATEH-3 .9 PERMIT NO. I 'R O 3 .3-3 10/82 500 EH 13-24 REV. 10/82