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a `may " APPLICATION FOR PERMIT SAN JOAQUIN LOBAYMEMTDISTRICT 1601 E. HAZELTOI iEMMON, CA l Telephone �0 PERMIT EXPIRES 1 A FR ISSUED re r' L m jNf M r1 at o 16 . bcr-;N s -f» e.Na�vIe_ Kort"I ON Ati{W, At�MEi�S ,,` 11NQ of c f_60K ','Lker E Application is hereby made to the SanJoaquinLocal Health Dis vf6Y"'MfthlittYCrS�Sl M a'r5[iYA,,ll the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. R ' LI Job Address laqv IVaV� D1—[UP City 5 Lot Size '" �aC�eS PM Owner's Name STAG 0SC-6WeAZa_Addr'ess 10,Y-6 "V%)V%) DlUQ Phone �@pserV�5 j53$ rrdlustr-1`o.E gyll� �,/ ago t Contractor Gt. r B AddressAve. License No, ys y Phone_ g" TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 1-1SYSTEM REPAIR ElOTHER oar i),J 5 DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES JAS! DISPOSAL FLD. ? PROP -LINE 110' r FOUNDATION AGRICULTURE WELL ? OTHER WELL.!UP 910 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Ria. of Well Excavation 5� r Dia. of Well Casing ❑ Domestic/Private— ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public Cl Other ❑ Delta Depth of Grout Seal Q 33 Type of Grout 6eN I I Irrigation --Approx. Depth IvrEastern Surface Seal Installed by EXD1GTa� 1191 GPS sert/tCLpS _ ` Repair Work Done ❑ Type of Pump Netye H.P. State Work Done + Well Destruction ❑ Well Diameter Sealing Material (top 50') Ce N tin" vis Depth 35 Filler Material lBelow 501 4 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION i.1 DESTRUCTION I I {No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence Commercial— Other ,.r - - Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth F SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. ❑ Jto Method of Disposal Distancinearest: Well Foundation Property,Line E f k LEACHING LINE ❑ No. & Length of lines Total length/size t FILTER BED ❑ Distance to nearest: Well _ Foundation Property Line SEEPAGE PITS 11 Depth Size Number a! - SUMPS - �Ll ..Disianceo nearest:, Well -.:.._�:._ _ _ .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. I 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 shalt not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X fflQ Title: Date: l -� R DEP ENT USE ONLY Application Accepted by Date /v Area 5_3 Pit or Grout Inspection by Date Final Inspection Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 M Tracy 835.6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 IFEE O AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMI-r'NO. r +.EH13-24}TREY.t/x s) ��. EH 1428 ( r r` '