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_ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZELi ON AVE., STOCICTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) th District for a all the work . This cation is Application is hereby made to the Co`uqui Ordinance lHl 549 for sewage or permit No 1862 for well//puomlp and the Runes and IR Regulations of the Sant Joaquin ( made in compliance with San JoaquintY 1 Local Health District. �3'�3k�� �� 6 Lot Size PM .� /"I v/ i City Job Address /►�fz ofFa4- /ya w�_a. Phone 23 f Owner's Name ! a C . IhIze/ � Address i /� I l��:r�Qx License No Phone �f� Contractor CD� 4'f�lJfi/li�i Address NEW WELL w WELL REPLACEMENT ❑ DESTRUCTION ❑ - TYPE OF WELL/PUMP: , -- - PUMP INSTALL-4TION� SYSTEM REPAIR'❑ OTHER ❑ )/Z iJP SEWER LINES Mo k� DISPOSAL FLD.164 PROP. LINE - f DISTANCE TO NEAREST: SEPTIC TANK FOUNDATION -� AGRICULTURE WELL OTHER WELL PlTS1SUMPS -�— INTENDED USE TYPE OF WELL PROBLEM AREA.v CONSTRUCTION SPECIFICATIONS j 7� bia. of Well Casing t�/�B ❑ Industrial ❑ Open Bottom �❑ Manteca b� Dia. of 1NeIl Excavation ' [fors { ' I � Tracy Type of Casing P V 4 Specifications Domestic I Private Gravel Pack Grout o M Public n Other i ❑ Delta Depth of Grout Seal r I I I+riyation f° Approx. Depth l I Eastern Surface Seal Installed by t' H P State Work Done _ Repair Work Done ❑ Type of Pump Well Destruction❑ Well Diameter Sealing Material (top 501 r _ / Filler Material IBelow 50') (t/ epth YPE rF EPTIC WORK: NEW INSTALLATION 11 REPAIR/ADD1T10N I 1 DESTRUCTION I i availableMo lc system wi within 200 feet.) if public sewer is ,� L j Installation will serve: Residence; Commercial _ Other f Number of living units: }-Number of bedrooms . , - - - - i Water table depth Character of soil to a depth of 3-feet: k i . Capacity - No. Compartments ! SEPTIC TANK ❑ Type/Mfg` Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line [ LEACHING LINE ❑ No. & Length of lines Total length/size l `r Foundation - Property Line FILTER BED ❑ Distance to nearest: Well y SEEPAGE PITS _ l I Depth Sire Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ y this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared rules and regulations of the San Joaquin Local Health Di§trict. 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 signature employ any person in such manner as1to"become subject to workman's compensation law s of California." Contrace�sonsrs 1sub suring bject t workman!scompensa- certifies the following: "I certify that in-the performance of the work for which this permit is issued, I shall employ p I F tion laws of Californ ,. The applicant t ca -for'all're red i spections. Complate drawing on reverse side. ./per r 2_ Signed X�"'�'��`� Title: 0�1Gr C'!!�1- Date: FOR DEPARTMENT USE ONLY Dale,lArea Application Accepted by .._._ �. Dat1t/ r RPit or Grout inspection by Dated Final Inspection b Additional Comments' Y - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy' 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 f 1r FEE CK RECEIVED BY DATE PERMIT NO. INFO AMOUNT DUE AMOUNT REMITTED CASH Sfr-�cor>~' k +.EH13-24(REV.I!n51 1 d5..�0v ' EH 14-211