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APPLICATION FOR PERMIT SAN JOAQUIN'LOCAL HEALTH:DtSTRICT.: . K801 E. HAZELTON Telephonti1209)466-6781. CA t OCT c v V4�� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVpIrRpO�`M�ITEN`T��AppL``''Hr(�E��ACQLTH E Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the WOfR-11BA1 Xe39AVA: fA 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. Q' ,/f�1 f� Job Address � o I/ L C Cm' L O,py- / Lot Size .PM t Owner's Name Hz✓N� r(JE-L'+FR Address SSM C� Y 'QOV� Phone l Contractor �tPurd/° h �Pl' Address/ YAddresstiYA N, 840nA W-4 License No Phone � l TYPE OF WELL/PUMP: NtW WELL ❑ - WELL REPLACEMENT .❑/ DESTRUCTION O - PUMP INSTALLATION U SYSTEM REPAIR,F�a OTHER O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES tM 'DISPOSAL FLD. PROP. LINE FOUNDATION. - AGRICULTURE WELL— -'- OTHER WELL_-� PITSISUMPS•� •>yi" INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial U Open Bottom ❑Manteca T Dm. of Well Excavation Dia. of Well Casing � Domestic/Private U Gravel Pack ❑Tracy Type of Casing _ Specifications �. r'1 Public ❑ Other 6.1 DebtM• Depth of Grout Seal Type of Grout I I litigation _.Approx. Depth�ue.cI 1 Eastern Surface Seal Installed by - rye Repair Work Done U Type of Pump IllH.P. '3 State Work Done �p�"7R Pr✓in 4 �1 Well Destruction ❑ Well Diameter Sealing Material Itop 50') - rs Depth Filler Material (Below '1 50t v+ TYPE OF SEPTIC WORK: NEW INSTALLATION III REPAIR/ADDITION I DESTRUCTION I I INo septic system permitted R public sewer is `.available within 200 feet.), Installation will serve:- Residence Commercial_ Other `1 1 Number of Irving units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity - " No. Compartments M PKG. TREATMENT PLT. ❑ _ ,. .. Method of Disposals Distance to nearest: Well Foundation Property Line I - LEACHING LINE ❑ No. &Length of lines Tote)length/size - �- FILTER BED U Distance to nearest: - Well Foundation Property Lire SEEPAGE PITS I I Depth Sim Number --SUMPS--,�DL Distance to nearest: ' Well Foundation --Property Line i DISPOSAL PONDS O ' 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, an(`P�- rules and regulations of the San Joaquin Local Health District. - t Horne owner or licensed a nt's signature cenifies the following: "I certify that in the performance o1 the work for which this permit is issued, I shall not employ any person in ch net as o ecome su l to workman's compensation laws of California." Contractor's hiring or sub-contracting signature candles the fotlowing "I c t that the pe nc of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- �` tion laws of Californi i The applicant t for all nd ' . Complete drawing on reverse side. Signed -Title: I'll tY A!/t"G'�iQ. Date: 10-2-27 - n r O EPARTMENT USE ONLY :Application Accepted by Data b _ Area 7/7 Data L j Pit or Grout Inspection by Date Final Inspection by / - Additbnal Comments: U Stk 466-6781 ❑ LOCH 369-3621 U Manteca SM-7104 ❑Tracy 035-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bos 2009, Stk., CA 95201 f ` FEE AMOUNTAMOUNT REMITTED DK R DUEECENEO BY DATE PERMIT NO. INFO CASH p� x FX IX24111EV. tV EH Is 2B t