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In APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1641 E. HAZELi O X1TON, CA Telephone 12491 466-678FILE ,Copy - PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) to the San Joaq r Nt con fort and well/Por" and the Rules and Regulations of the San Joaquin de uin Local Health District for a permit to construct and install the work herein described.This application+s Application iscompliance with San Joaquin County Ordinance Na 549 for sewage made in Local Health District. /_ f tc Ci Lot Size j Job Addre ' Phone QAddress Owner's Nameg7-Z� Phon License No. ddressDESTRUCTION ❑ Contrac WELL REPLACEMENT ❑ ❑ TYPE OF WELL/PUMP!, NEW WELL OTHER ❑"' SYSTEM REPAIR ❑ PROP. LAVE PUMP INSTALLATION ❑ DISPOSAL FLD. SEWER LINES �- OTHER WELL— PITSISUMPS DISTANCE TO NEAREST: SEPTIC TANK � AGRICULTURE WELL FOUNDATION �----- TYPE OF WELL PROBLEM M AREA CONSTRUCTION SPECIFICATIONS Dia. of Weil asir4 INTENDED USE p Manteca Dia. of Well Excavation Specificatwns El Industrial ❑ Ogen Bottom Type of Casing ❑ Gravel Pack ❑ Tracy Type of Grt ElDomesticlPrivate n Delta -Depth of Grout Seal f 1 Public M Other Surface Seal Installed by J 1 Irrigation _.:APprox. Depth I I Eastorn State Work Done Type of Pump --� H.P. Repair Work Done ❑ Sealing Material (top 501 Well Destruction ❑ Well Diameter Filler Material (Below 50') Depth per it public sewer is _ REPAIRIADD1 .101 l 1 DESTRUCTION l i a�aifabe'wtlin 200'feet.f h_ TYPE OF SEPTIC WORK:• NEW INSTALLATION . r � r Commercial— Other installation will serve: Residence I II Number of living units: O t .-- Number o drooms Water table depth 2 -� Character of soil to a depth of 3 feet: Capacity— No. Compartments SEPTIC TANK Type/Mfg Method of Disposal o-i { PKG. TREATMENT PLT.❑ wQ___ Property Line U v Foundation r Distance to nearest: Well----t Total length/size K No. & Length of lines / property Line LEACHING LINE Foundation + FILTER BED ❑ Distance to nearest: Welles — If �-+ Number Size Depth J Property Line — PkGE PITS / Foundation -" -'SUMPS- L� Distance to nearest: Well t DISPOSAL PONDS certify that l have prepared this application and that the work wordinances. state Paws, an ❑ ill be done in accordance with San Joaquin county I Fie"reby c V rules and regulation of the San Joaquin Locale Health District. I certify that in the performance of the work for which this permit is issued, 1 shalt not Home owner or licensed agent's signature certifies the following:or " to ersons subject to workman's compensa an arson in such manner as to become subjsct�ohe work for which this permit is issued, empnty ptor's hiring or sub-contracting signature employ Y Q I certify that in the performance o . certifies the following:" tion laws of California." ctions. Gomplete drawing on reverse ;d�. Date. The applicant mus ll for all r red in pe i�.r Title: _ Signed X FOR DEPARTMENT USE ONLY r Area Data Date Application Accepted by ;nal Inspection by N ate Pit r Grout inspection by 'Additional Comments: ❑Tracy 835-638595201 (i Stk 466-6781 ❑ Lodi 369-3W ❑ Manteca 823-7144 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA CKRECENED BY DATE PERMIT'NO. FEE AMOUNT DUE AMOUNT REMITTED CASH INFO d_0 �.EH 7324(REV. - EH 14-28