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APPLICATI./N FOR PERMIT # !� SAN JOAQUiNkOCAL HEALTH DISTRICT PERMIT NO. IOCKT1601 E. HR 'hone AVE.,) 466-6781 DATE CA DATE ISSUED R� Telephone ( ) 1_ 91� I !. � PERMIT ERPIRES 1.°YEAR FROM.DATE ISSUED (Complete in Triplicate) Permit to construct and/or install the work herein Application is Y }lance with S pt ty Ordinance No. 549 for sewage or No. 1862 for well/pump hereb made to the San Joaquin Local Health istrict for a p 3 I described. This app}}cation is made in compri and,the Rules and Regulations of tt�e San Joaquin Local H tubdivision Name? U�Z -�-• � ••f @,�5� Phone 7 Job Addres 1 -Address Phone 3 -d-7 E Owner's Name 4 V e--S License No. 3 { Contractor's Name ' WELL REPLACEMENT ❑ DESTRUCTION ❑ • NEW WELL � OTHER ❑ -- TYPE OF WELL/PUMP^WORK: SYSTEM REPAIR L�,. PUMP INSTALLATION .~ '' DISPOSAL`FL'D,F_� PROP•. LINE +-^ � ` x ANK ,SEWE?, LINES.. PITS/SUMPS DISTANCE. TO NEAREST:,SEPTIC„T- ,�- -_1 OTHER WELL f ' FOUNDATION C AGRICULTURE WELL �� f PROBLEM CONSTRUCTION SPECIFICATIONS INTENDED 7Y?E�- OF WELL ----�� Open Bottom ❑Manteca Dia. of Well Excavation Industrial t ❑Tracy Dia. of Well Casing ' ❑ Gravel Pack �g . DomesticlPrivate ;❑ ❑Delta Type of Casing r T Public ❑Other tions IrrigatiEastern Specifica ; ��- Approx. / }❑ on } Depth Depth-of Grout Seal .� ❑Cathodir,Protection 6 1 't� E Type of Grout Geophysical 1 ` 01Surface Seal Installed by J U OtherState WorkDone .� _ Repair"Work Done ❑ Type of Pump t, ' --H' y i, F50,)' �Y C I` s ,�.o..�Sealing Material (top ` Wel l,Diamet,er'�� r f Well Destruction ❑ Filler Materiall(Below 50') ff�J Depth ^ "` sewer d if TYP PTIC WORK: NEW 1NSTRLLRTION F I REPAIR/7ADDITION No septic tank or seepage p1availableewithinu200cfeet.) is JCommercial Other F Installation wl ve: Residence Lot size _��- u:' _N umber of bedrooms Water table depth t Number of'living• nl { _._ Character of soil`to a depth ,of 3 I Capacity ��, No. Compartments Te/Mfg f SEPTIC TANK ❑ Type/Mfg Capacity �•_ Method of Disposal PY,G. TREATMENT PLT. ❑ Type/,Mfg tion SEWAGE SYSTEM Distf Property Line E nce to nearest: Well �- - DESTRUCTION Q Tota No 'f& Length,of"11nes Foundation_ t Line . ��- LEACHING LINE [J .� r Distance to nearest: Well F^1LTER"BED ❑ Number Property Oept!h _��_� Size Line ` SEEPAGE PITS Foundation j SUMPS ❑ Distance to nearest: Wel I- - DISPOSAL PONDS _ ❑ ' I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county and signature certifies the following: 'I certify that in the performance of the work for which this ordinances, state laws, in Local and rules and reguertifienosuchfollowf the San inagsuto become subjectealth }torworkman� compensation laws of California." t Home owner or licensed agent'sp any p 1 t permit is issued, 1 shall not employ n tore certifies the following: "I certify that in the performance of the work far which Contractor's hiring or sub-contracting signature g Y p this permit is issued, I shall employ persons subject to workman's compensation laws of California. 3 Date: I The applicant mu t call for all required ins.pectians. Complete drawing mon rever��e• Title-. I'L 111,11 Signed X ❑ Stk 466-6781 r FOR DEPA SENT U ONLY Area . Application Accepted-by ,, Lodi 369-3621 Manteca 823-7104 1 Additional Comments:",.� Data,"''` ❑ 835-6385 Pit or Grout Inspection by Date ❑ Tracy Final Inspection by160 E'�' Hazel on Ave., P^0. Box 2009, Stk., CA 95201 Applicant-- Return all copies to: vironmental Health Permit/services � DATE PERMIT NO. AMOUNT REMITTED RECEIVED BY FEE BASE AMOUNT DUE o *� IN �p S_ 10/82 500 EH 13-24 REV. 10/82 14-26