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Vf �_ APPLICATION FOR VER IT r SAN JOAOUIN LOCL HEALTH IS SRI I 34, 1601 E. HAZE I ON AVE.,tiSTOCK ON C Telephone (209) 466-6781 b I PERMIT EXPIRES'1 YEAR FRO DATE ISSUED .I 1 t (Complete in Triplicate} t l 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 Ordinance No.549 for sewagelior No. 1862 for well/pump,and the Rules and Regulations of the San Joaquin Local Health District. Job Address 'J�?S! /�i( /c��'G/S r,~ City ,i1,Tit`/1�s� Lot Size a` X PM Owner's Name t/r/IrI2V/A/' ,�.C�D A 457`/Y/�[3�.Tcas Phone Contractor c 01� Address Q License No.,29�Qw�Phone._ ry ' ----- _ r_ _... . - — Ph- �TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE"'"!'"",X TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS © Industrial F] Open Bottom El Manteca Dia-of WeII,Exca ation Dia. of Well Casing ❑ Domestic/Private .I ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ? o ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout x ❑ Irrigation ____ Approx. Depth El Eastern Surface Seal-Installed by 1 _ Repair Work Done C2 Type of Pump H.P. �''. State Work Dane a s F w { Well Destruction ❑ Well Diameter Sealing Material'Itop'50'I � r. Depth Filler Material IBelow 50'1 i TYPE OF SEPTIC WOFAK NEW INSTALLATION ❑ REPAIR/ADDITION N DI=STRUCTION-M (No septic system permitted if public sewer is ,f '?available within 200 feet.) # Installation will serve: Residence AL Commercial_ 0fhe-td—: ice.-1'" 11 _'.""" - ,...: was Number of living units:� Number of bedrooms Character of soil to a depth of 3 feet: �i�o,t - - Water table depth + i ,,,,SEPTIC TANK ■ .:Type/Mfg Capacity I l No. Compartments PK'6. TREATMENT PLT. ❑ 7 Method of Disposal l Distance to nearest: Well Foundation Property Line i l rj LEACHING LINE ■ No. & Length of lines r40'' Total length/size _ 40' FILTER BED ❑ I'Distance to nearest: t Well t Foundation Property Lineks a SEEPAGE PITS is Depth 25' r Siie: 33 Number __ I k ,SUMPS_, '`QZCistance.to.nearest:r _Well _""'" Foundation jam(!_.. _' .;Property Line 10� DISPOSAL PONDS Cl I hereby certify that I have prepared this application and that the work will be done in accordancewithSan Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I =1�NN-� , I f 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."Contractors hiring or sub-contracting 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." i' The app I' t must call for all required inspections. Complete drawing on reverse side. a } Signed �-�+ Title �Q/r�.a.o_1/l_1 Date: FOR DEPARTMENT USE ONLY Application Accepted by V. Area L:... Pit or Grout Inspection by yk) Date Z Final Inspection by Date Z ` A ditional Comments: �` I Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 J. ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 16611 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOl1NT'DUE'S ^ AMOUNT REMITTEDV'TCASH~ RECEIVED BY"� DATE '� PERMIT�NO. INFO + EH 13-24IRM i/H5Y w �� EH 14-28 y ~