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} APPLICATION FOR PERMIT 1P P"(v SAN JOAQUIN LOCAL HEALTH DISTRICT RE Telephone hone 209 OCKTON, CA J�~� 19�� 1601 E. H p } 6781 N�A� PERMIT EXPIRES 7 YEAR FROM DATE ISSUED �� M�IS�R`q\C�S � . (Complete in Triplicate) p+c[ZM Application ishhereby 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 sewage or No. 1862 for well/pump and the Rules and Regulations of the Sart Joaquin Local Health District. torts C�'Tc �UMIp /o Job Address Ci .:r1v AA1�r rr / l �I�/'f�al�Jr city Lot Size PM r Owner's Name _- Cdfr 4 A4 o 0 % _ Address 2 Z 2 Phone 3S3 67 Pg 4 Contractor's Name e V )p w License No. sr i aGS6y8 phone 09? 72 7 33 + TYPE OF WELL/PUMP: N WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION` SYSTEM REPAIR ❑ OTHER ❑ ,�PISTANCE TO NEAREST-SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE Y FOUNDATION AGRICULTURE WELL -�OTHER-WELL PITS/SUMPS V� .1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom If Manteca Dia, of Well Excavation Dia. of Well Casing ❑ Domestic/Private X Gravel Pack ❑ Tracy Type of Casing Specifications Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. D O State Work Done Well Destruction F1 Well Diameter _�0 If Sealing Material (top 50') , I Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted i#public sewer is i Installation will serve: Residence_,_ Commercial_ Other available within 200 feet.) Number of living units: Number of bedrooms �t Character of soil to a depth of 3 feet: �I y _Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Q Method of Disposal .. Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: V7 Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Y 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." Contractors hiring or sub-contracting signature unt,3 . ago-�",Wifv th�t�ijt performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- The applic1Wt4AuW%P1Mr4dVW*Ad inspections. Complete drawing on reverse side. Signed �G SANTA CLARA, CA. 95050 �s'1 �-W / ;✓�./f Title: �' �' 45 Date: 7Z/7S�291& F �RE RTME T USE ONLY Applicati 7cepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Q G Additional Comments- ;K Stlk omments:;KStk b ❑ Lodi ❑ Manteca-.823-7104 ❑ Tracy-835-6385 Applican�tuil copies tort Wealth Permit/Services 1601 E. Hazelton Ave., P O BoxCA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. INFO CASH 'EH 13-24(REV.101831 ( 35 .� 35. 0 1`1111 in/�-1;/y *rt t426 "'111�� t 1 f r r i i•s `�