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L _ r APPLICATION FOR PERMIT r Z, ., SAN JOAQUIN LOCAL HES T DISTOCKTON,RCAT f 1801 E. HAZE i ON AVE., Telephone (209) 466-6781 ¢, PERMIT EXPIRES 1 YEAR FROM DATE ISSUE (Complete in Triplicate) This applrcztion is .549 for sewage or No. 1862 for well IPump and the Rules and Regutations of the San Joaquin hereby made to the San Joaquin Local He It District for a permit to construct andr`or inst_ali th e work herein descn Application€s uin County Ordina ce rnade in compliance with San oaq Local Health District. Q Q V� /`/`7? L PM Q P w ,}�y� City Lot Size ` h � ra' r ,yob Address Wa 9q Phone bre ��q, �(' Address f Owner_ Name I � _Phone ( License No. �0� rTO RI� A btt 1I Address pESTRUCTION ❑ Contractor — WELL REPLACEMENT ❑ OTHER ❑ NE WELL > TyPE OP WELLIPUMP: SYSTEM REPAIR ❑ PROP. LINE PUMP INSTALLATION ❑ DISPOSAL FLD.� SEWER LINES .� PITSISUMPS DISTANCE TO NEAREST: SEPTIC TANK �— OTHER 1VELL1 �.—.-- AGRICULTURE WELL �-- FOUNDATION _�r— TYPE OF WELL PROBL CONSTRUCTION 5PEC1FlCA IONS Dia. of Well Casing I INTENDED USE Manteca Dia. of Well Excavation G Specifications ❑ Industrial ❑ Open Bottom Type of Casing Gravel Pack ❑ Tracy 1`4 Type of Grout Domesti - ❑ Delta Depth of Grout Seal ❑ Public ❑ Other Surface Seat Installed by ---Approx. Depth Cl Eastern tate Work Dane ❑ Irrigation of Type Pump H.P. a e I a Repair Work Done C: �� Sealing Material (top 501 B�Y4 all Destru tin Well Diameters*. f � _ Filler Material (Below 50'1 stem permitted if public sewer is �I Depth = ----�— DESTRUCTION © (No septic i ill9in�fp REPAIR/ ❑ available within 200 feet.) # TYPE OF SEPTIC WORK.: NEW INSTALLATION ❑ 0� Commercial w Other 1--- ;. Installation will serve: Residence Water table depth --�— Number of living units: Number of bedrooms�. 6 No. compartments Characterof soil to a depth of 3 SEPTIC TANK 0 TypeJMfg--�~ Method of Disposal ; PKG. TREATMENT PLT. ❑ _�� Foundation — Property Line Distance I nearest: I Total lengthlsize�— ❑ No. & of lines property Line�—�-- LEACHING LINE We111— Foundation_.�-- FILTER BED ❑ tante to nearest' Number ❑ Depth S+ze Property Line�---- (� SEEPAGE PI Well�1 Foundation��— J SUMP ❑ Distance to nearest:_ tate laws, and POSALPONDS �' ❑ i that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, .. I hereby'certfY rules and regulafions of-the San sonaiureLocal artifiesthe fol,orwing: "I certify that in the performance of the work actfor which this permit is issued, l shall not Home owner or licensed agents g nsation laws of California." Contractor's p6r ons�subject t workman'scompeturo employ any person in such-nanner.as to become subject to workman's comps certifies the fallowing: "l certify that in the performance of the work for which this permit is issued, I shall employ p tion laws of California." n �� The applicant st call for all required i s coons. Complete drawing on reverse side. Date: Title: Signed $ Area �L € FOR DEPARTMENT USE ONLY Date — — �/ Date Application Accepted Accepted by Dat :Final Inspection by e j t Pit or Grout Inspection by ❑ Tracy 835-6385 tk., CA�1 Additional Comments: ❑ Manteca 823-7164 © Stk 466-6781 ❑ Lodi 369-3621 li nt:- Return all copies Environmental Health�lvicsi 1661 E. Hazelton Ave. P.O. Box 2009. ApP Rs-,N � 0 �Y. CK# RECEIVED BY DATE PERMIT NO. ' FEE AMOUNT DUE AMOUNT REMITTED GASH r� INFO + EH 13.24 SREV.V s 51 [ EH 1428