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bU APPLICATION FOR PERMIT I SAN JOA QUIN LOCAL HEALTH DISTRICT { X601 E. HAZELiON AVE., S -6781 N, CA Telephone 12091 466 6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` 1. (Cornplete in Triplicate) lication is e or No. con fort and/or i and the Rules and Reguiations of the San Joaquin the San Joaquin Local Health District Sa�apermit to construct and/or install the work herein described.This app Application is hereby made to Ordinance No.54 or g [f tl t�}• made in compliance with San Joaquin County� PM, aC�'\ Local Health District-0 �� J�Vv D ice{Size t,,3 3 ♦ jot) Address � Phone �D Address Owner's Name � e icense No. �!" Phone t f 1 �►{�� i AddresspESTRUGTION Cl Contractor !' NEW WELL ❑ WELL REPLACEMENT ❑ pTHER CD TYPE OF WELL SYSTEM REPAiR ❑ 1117 PROP. LINE j PUMP INSTALLATION ❑ DISPOSAL FLD.r— 'r SEWER LINES --- pITS/SUMPS ( OTHER WELL -- DiSTANCE TO NEAREST: SEPTIC TANK �1— AGRICULTURE WELL r— FOUNDATION 1� _ ',Y l 'W PROBLEM AREA CONSTRUCTION SPECIFICATION Dia. INTENDED of Well Casing -TYPE OF:WELL �� l r USE ❑ Manteca - Dia. of Well Excavation r ❑..Open Bottom U Specifications ❑ Industrial '1 ❑ Tracy Type of Casing D Type of Grout Q Gravel Packer Depth of Grout Seal �Public DomesticlPrivate t ., ., � ❑ pelta 'Surface Seat Installed by i f Approx. Depth I'i Eastern State Work Done'"� I 1 lrrigation3 Repair Work Done ❑ Type of Pump'''"' H.P. Sealing Material (top.501 Well Destruction ❑ Well Diameter-� Filler Material (Below 50'! " } I I ermitted if public sewer is I Depth available within 200ifeet.i TYPE OF SEPTIC WORK: NEW INSTALLATION I l .NEPA /ADDITION t 1 DLSTRUCTION 1�lN't eptic�system a Residence Comrnerial Other installation will serve: Number of living units: Number of bedrooms' { Water table depth I Character of soil to a depth of 3 feet: F No. Compartments, Q Type/,Mfg F � � Capacity-- r ' SEPTIC-TANK r Method of Disposal r w PKG TREATMENT PLT. ❑ Foundation�_�= Property Line Dist ice to nearest: Well ` Total length/size LEACHING UNE ❑ No. & Length of lines Foundation Property Line FILTER 9ED ❑ Distance to nearest: Well 1 . � Number SEEPAGE PITS 4 11 Depth ; Size- _ ' s '"i Foundation ----" " Property L%1 SUMPS } L� Distance to nearest: jW yr w� ,t { DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San JoKquin county ordinances, state Laws, and l not rules and regulations of the San Joaquin Local Health District. Owina Home owner or licenseeagent'sanne gas torbecome subject workman'srtcoympansation lthat in the a ws Califorrnia.- Contractor'sth li gt or sub-contracting it is lsignlaturre employ any perftin certifies the folio inn: "i c fy that s the oe subj1`1 of the work far which this permit is issued, I shall employ persons subject to workman's compensa- an tion laws of Clalif rnia." mow = The applican t call r r ire s tions. mptete drawing on r ve se si a ry �} LAA,, Date: . L/r✓IIY Title: _ Signed X r FOR DEPARTMENT USE ONLY _ Data �f� Area I' Application Accepted by �� pate 15� !pL�-6 Final Inspection by ' 'Pit or Grout Inspection bypate W - Additional Comments: ❑ Stk 466-6781 ❑ Lodi 1369-3621 " ❑ Manteca 823 7104 elton Ave., P.O.Tracy 835-6385, P. Box 2009,1;Stk., CA 95201 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. HazI CK RECEIVED BY GATE = PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH g3 INFO 3 ti S Aq +.EH1321(AEV.iins) ' /. EH 10.28