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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT S�gY'LM 1fib1 E. HAZE:.iON AVE., 6 - .7 DN, CA �L r,Nr1S 0`9 TelOphafle 1249}450 114 col �TXwtEN ,E+ A11S19111I a PERMIT EXPIRES 1 YE� �GINL 9] i�kYF (Complete in Triplicate# V S hcat:nn is rk Application Is hereby made to tf•e San Joaquin Local Health District fora permit to consnu ell1pu Install the Rut and lH Regulations ai he San Joaquin « made in compliance with San Joaquin County Ord'inan:e No.549 for sewage or No.1862 I^r wellrpump Local HeaSth District. �_ .7toC'f Lot Size --�-� �=�� ?1145W. Chr.rt[. t;^ti carr 05—:393' Joh Address " cl;c, sf. FIT: ;less Phone --- ?r,�r 'tf1'•f]',;.�j Address +F r, 36� Owner's Name� - t ` ' „f�.�•, ., ':C1:Ct_�ceRse No. :77,�3• •�-Phana� !!w zCC{Tt'f'` Addtess��' ❑ DESTRUCTION Q fn; r .Lr'V 4-4 t�4 Conlratlor NEW WELL ❑ WELL RE�LAGEMENT OTHER LL=TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ _ PUMP INSTALLATION ❑ D1S705AL FL O• pTSISUMPS SEWER LINES ��- .� DISTANCE TO NEAREST: SEPTIC TANK ��-� AGRICULTURE WELL OTHER WELL YOUNDATIONt+t + INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS� Dia.of Well Casing —^f� ❑tii:nsaca Dia.al Well Excavation��- apatifications ❑Open Bottom `' ❑Indusidal O Tracy Type of Casing r ++�,�,�• _- ❑.Gravel Pak Type of Groul ❑ DomesticlPrtvate [i Delta Depth of Grout Seal ^�� . l'!Public fl Othern, Surfer Seat Installed by r a -pRhfp1 Depth I 1 Eastern Stale Work Done_ I I Irligation- • r•.u"",t 1..." H.P. Repair Work Done 0 Type of Pump �� •s I' Sealing Material Trop Well Destruellun ❑ Well Diame[etr Filler Maw°low 502 Depth availehle within 200 feet TYPE OF SEPTIC WORK: VEW 1NSTALlA7E0N I i REPAIRlADDITION I i DESTRUCT'ON 1 I INo septic system permitted it public sower is Instaltstion will serve: ReEldence, Commercial Other r units: Number of bedrooms �_Wa'et table depth Number Of living No.Compartments Character of salt do a depth of 3 feet: Capacity�� anal SEPTIC TANK Cl Type/Mfg Method o1 Disp PrG.TREATMENT PLT.17Foundation -� Property Lina 1-^ Distance to nearest: Well�� Total length/site Cl No.&Length of lines .—�-- Property Lina r- LEACHING LINE Well r. Foundation�1 FIf.7E'R IED 4--i Distance to nearest: Number t I Depth ��Slte_ Property Line y--� SEEPAGE PITS Well- .r- Foundation r- SUMPS Ll Distance la nearest: - DISPOSAL PONDc ❑ th San n cenjull ' alth Dr's.trlet. permit is issued,I shalt net .eer!ify that 1 have prepared this application and that the work will be done in accord snca o the work far iwfrich this nances, i Signature 1 hereby ulairrs of the Sen Joaquin LOC aI H I cerl;fy that In.he perform rulsa end rag ansa" Home owner W 11c•:css�agent's signature canities the tt to following:" shall employ persons subject to workman's come employ any parson in tush manor es to bee Ansmancaca4the work[orwh ch this Perm it la issued,fl luta:'Cenilaeto+'s hiring or sub-Contracting Caol l the following:"I c+rl;fy the'in th Po f 1n inspections.... ll r / J lion laws of C J tics s Cali l "t ser I inspections. fomplela sawlog on rev Viso; 7 j.t Pr (`: 1 efe: r T11 ha app �• ills: Signed X e r(: '- FOR DEPARTMENT USE ONLY rllt. Date Area =..,.. <. Date--- -�- ' Application PiCCOPted by r• _ Date Final Inspection by - Pli of Grout Insps^tion by . ..' r,•,'(Y(...: .:!.:. '.• ,. •' .. ,. .�.E ,.., r- •t.. -- - r. B35 63135 Apilic �'�• Tracy Stk.,CA 9520 Additional Comments: ❑Lodl 3,3621 ❑Manteca 823.7104 C7 ❑Sek 466.67RI - 0 Stkant•Return all caps to-Environmental Health PetmltlServlcea 1601 E.Hazelton Ave.,P.O.Box ' PERMIT!O r RECEIVED BY DATE FEE AMOUNT DUE AMOUNT REMITTED CASH 7 YY INFO .+�rj •EH 13'211RF1.r+rrsl -, E1414-20 i`:ws __ _- ASf7R�S11eHPK®1!L'aa .. _