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APPLICATION, FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. NALe�� T0N, CA Telephone 209? 466-6781 ' • ..1 FERMIS EXPIRES 1 YEAR FROM DATE iSSUE0 i• + fete in Triplicate), (Complete application is ;rs permit to construct and/or install the work herein described•This made to the San Joaquin Local Health District for a mor No.1862 for well/Pump and the Rules and Regulations of the San Joaquin ' Application is hereby i made in compliance with San Joaquin Cou�tl Ordinance No.549 for sewage �/j �� r Local Health District. 1 ;r / ��J1LC Lot Size'— y -- PM_--- ty tiL—K�= .a by Job Address — ,� , , � � phone ��LL Address _ — owner's Name v _ --_Phone. ` k --�License No. - • Address — , DESTRUCTION C Contractor_ --- WELL REPLACEMENT J OTHER l; NEW WELL � TYPE OF WELL/PUMP: SYSTEM REPAIR l PROP. LINE --- - — PUMP INSTALLATION CL DISPOSAL FLD._— p1T5/SUMPS = ` SEWER LINES OTHER WELL- 0 STANCE ELL DISTANCE TO NEAREST_SEPTIC TANK _--- AGRICULTURE WELL =— FOUNDATION — 0 TYPE Of WELL PROBLEM AREA CON STRUCTION SPECIFICATIONS - Dia of Well Casing ---- INTENDED USE --!�-- Dia. of Well Excavation_.--- --- ] Open Bottom �. ❑ Manteca _ r Specifications' ( industrial r L Tracy Type of Casing_--- — Type of Grout ----- (f C Domestic/Private L-1.Gravel Pack Depth of Grout Seal — ---- — ---- C1 Other [I Delta L Publicoz. Depth r G Eastern Surface Seal Installed by— Appr ------- =i H.P. --�--- State Work Irrigation ' Repair Work Done L Type of Pump --_-_- — — — Seating Material (top 50�} Well Diameter --- — Well Destruction F. Filler Material blow 50"} — Depth—�-- — tic system permitted if Public sewer is i available within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION L DESTRUCTION [� o seP O�r Installation will serve: Residence Commerclal— --- - -- i Number of be ✓��— bedrooms Water table.depth— —�- — Number of living units: .— No. Compartments — 1. Character of soil to a depth of 3 feet: r`'—J — Capacity "-- -- Type f9 �- I f Method of Disposal — SEPTIC TANK YPLine__/ _ PKG.TREATMENT PLT.E J Foundation - Property --- Distance to nearest: Well 1IL — _�---- Total lengthlsze--� �-- � ---- Length of lines —?—� No & Leng —-- I LEACHING LINE �'Ni —_ Foundation--�— Property Line — --- FILTER BED -1 Distance, to nearest: Well Number------�-- -----_ Depth --`�=`�T -Size_— — / Property Line SEEPAGE PITS Foundation—' 5 f laws, and SUMPS F! Distance to nearest: Well��-- i DISPOSAL PONDS certify that 1 have prepared this application and that the work will be done In accordance with San Joaquin county ordinancis es, • 1 shall not I hereby fY that in the performance of the work for which this pe rules and regulations of the San signature certifies Health following: "I certify Nome owner or licensed age 9 to persons subject to workman's compensa compensation Jews of California." Contractor's hiring or sub-contracting signature employ any person in such manner as to become rttsubject iabce of these wok for which this permit is issued.I shall amp Y P certifies the following:"t certify that In the pe tion laws of California." The applicant must call for all required inspections. Complete drawing on reveree side. Date:,---- ,-- --f— Title: Signed X_— --- OR DEPARTMENT USE ONLY Area — Date } Application Accepted by — Date1-�- 1 � Qe `—a`f� Final Inspection-by it r Grout Inspection by Cad4. � - + { Additional Comments: _--`�--- L Tracy B3`e., P.O. . Stk., CA 95201 U Stk 466-6781 ❑ Lodi 369-3621 C7 Manteca 823-7104 Ei Stcant Return all copies to: Environmental Health Peart/Services 1601 E. Hazelton Ave., P.O. Boz 2009, C RECESVED BY DATE: PERMIT-`NO. FEE AMOUNT DUE AMOUNT REMITTED CASH INFO 7 1 . EH 1324(REV. EH 14-26