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F Fill i �yy 1 r, { _ —APPLTCATIOTTFOR_PERl17l7T SAN JOAQUIN LOCAL HEALTH DISTRICT -E-+1A-ZE—,TON-A-Vf`-5fi'Dt-r lul ;C4 f ,l Telephone (2091466-6781 �j PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicatel Application is he,eby 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ��n City f10 Ir=..Lot Size 4 =c±11^i PM �} Owner's Name.._,_ !1 L` •. S6ddres " Phone r ¢ I Contractor_ ,�,��Address - License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ - PUMP INSTALLATION ❑, SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.LINE - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ItL1INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑Industrial ❑Open Bottom ❑Manteca Die.of Well Excavation Dia.of WeII Casing DomesticlPrivate 111:1Gravel Pack Tracy Type of Casing Specifications ❑Public f I Other H Delta Depth of Grout Seal Type of Grout I I Irrigation _Apprex.Depth I I Eastern Surface Soul Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Dane_ Well Destruction ❑ 'Well Diameter Sealing Material/top 561 F . Depth Filler Material{Below 501 TYPE OF SEPTIC WORK: .NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) _ Installation will serve: Residence Commercial_ Other b!� Number of living units: Number of hedrogms J 0 r Character of soil to a depth of 3 feet: Z !✓max Water table depth Q SEPTIC TANK &I Type/Mfg C pac'sty � �a No.Compartments PKG.TREATMENT PLT.❑ ��rr�r Method of Disposal Distance to nearest: Well--z� Foundation I:3 'Property Liner LEACHING LINE lot' No.&Length of lines 2 410 Total length/size - O FILTER BED ❑ Distance to nearest: Well 10 Foundation- ��Property Line SEEPAGE PITS i I Depth __._- .Size - it NFum��b -3��er _ SUMPS ❑ Distance to nearest: WeII Foundation—Tt�---Property Line FFF 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 DRtrict. - Home owner or licensed agent's signature certifies the fallowing:•'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."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, .ihall'enlpldy parsons subject to workman's compensa- lion Yaws of California." The app6can ust call for ail required inspections.Complete drawing on reverse side. Signed Title: _ nlAl-f-1 Date: S^ _ FOR DEPARTMENT USE ONLY 4 - Application.Aceepted by e2DateV ( Area r' �Py"-6r Gro6tclespection by Date Final Inspection by v Date Additional Comments: -- ❑Stk 466-6781 ❑Lodi 369-3621 ❑Manteca 823-7104 ❑Tracy 835-6385 Applicant-Return all copies to:Environmental Health Permitl5e5vieas 1631 E.Hazelton Ave.,P.O.Box 2009,Stk.,CA 95201 r INFO /AAMOU(�N5}T DDE AMOUNT RFMIITTFD =' 1,124 , RECEIVED BY �J7 PATE ONCASH t.EH IREV.rirvel EH 4-2t 20,10 89 '