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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t LT • A Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) A P A t'1�j , +, Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the we A, �Tfijs'application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules aig4�Reglations of the`San Joaquin Local Health District. .'j /` �� `�• „s �� •.`. fig" i Job Address ¢ 5Oct &4+r"VO,n1 � _ City �ANE Lot Size Gl r�C� PM Owner's NamA.�#EL/Je0N Ui `r+4• /1V4Address Z4/0 nf& ;Vo X s1mv I SA'N 441foly 9458.3- �n� fS 2- X5,2 Contracto'ey;Gw&/'o uELG AW4U;dddress D 4-.061f:•r MWO tV'e a No. 4843Y0 Ph on W4►5 613 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT.❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X DISTANCE TO NEAREST:'SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 50 FOUNDATION AGRICULTURE WELL OTHER WELL40�— PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.of Well Excavation 7 iA. Dia. of Well Casing ❑ Domestic/Private Gravel Pack JW Tracy Type of Casing PVC Specifications S/ab O.OLC. f`7 Public F] Qther P Delta Depth of Grout Seal 5 Type of Grou^CJ"OA' 6051Y - I I Irrigation �..Approx. Depth I 1 Eastern Surface Seal Installed by&4_1 4*#gCT A10'GL 00?044 + Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction X Well Diameter'. Sealing Material Itop 50') edr.-V w Ley 7i �°fJ� Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l 1 DESTRUCTION l I (No septic system permitted if public sewer is J F' available within 200 feet.) e Installation will serve: Residence�F Commercial— Other Number of living units: Number of bedrooms . Character of soil to a depth of 3 feet: Water table depth 111 SEPTIC TANK ❑ Type/Mfg I' Capacity . No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line R LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line P SEEPAGE PITS 11 Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 regulations of the San Joaquin Local Health District. 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." Contractor's hiring or sub-contracting signature certifies the following:"!certif tat in th2_ggiJw9,aance ofA work for which this pe�rm,it is issued, I shall employ per s subject to workman's compensa- tion laws of California." 'U'�/d'%�s The applicant m for a r ired ins ctions. Complete drawing on reverse sidle. > ~v Signed X i6e 15404*AAF tle: fy 47r!'c o Co�! Date: 46 F DE ENT USE ONLY Application Accepted by Date �3 9 Area Pit or Grout Inspection by Date Final Inspection b `�' v Dat Additional Comments: / 0 ❑ Stk 466-6761 ❑ Lodi 1 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C K H RECEIVED BY DATE PERMIT'NO. ��7 -120 . a 0 0SO99 � G/�Z0/9/ 9/—(J r EH 13-24 TREY.i/n 51 � EH 14-28