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`,APPLICrTION FOR PERMIT SAN JO,,Q1 i!, LOCAL HEALTH DISTRICT 1601 E. HAZELiON AVE., STOCiTON, CA PERMIT t.O. Teiepnone (209) 466-6731 - DATE ISSUED T j PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r Application is hereby made to the San Joaquin Local Health 0istricL 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address tiq 1._ !�)40 P_ A Subdivision Name Owner's Name ICH U S �H S Address I 1 01 31 Q4ng ry�/�jJ ��Z Phone S� Contractor's Name *#. License No. Phone ^ TYPE OF WELL/PUMP WORK: NEW WELL C WELL REPLACEMENT ❑ DESTRUCTION C Vu PUMP INSTALLATION SYSTEM REPAIR C OTHER I I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (ji I� Industrial U Open Bottom 0 Manteca Dia. of Well Excavation U Domestic/Private []Gravel Pack C Tracy Dia. of Well Casing Public C Other CjDeIta Type of Casing C Irrigation Approx. Eastern C Cathodic Protection Depth17 Specifications Depth of Grout Seal Geophysical Type of Grout U Other Surface Seal installed by Repair Work Done Type of Pump H.P. State Work Done Well Destruction C Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION � REPAIR/ADDITION C (No septic tank or seepage pit permitted if public sewer is v, available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of living units: S/NG//� -ber of bedrooms Lot size _ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity QQ No. Compartments Z- PKG. TREATMENT PLT. C Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well (�S/ Foundation 'aQ Property Line (ppy DESTRUCTION LEACHING LINE No. E Length of linesTotal length/size FILTER BED (_f Distance to nearest: Well Foundation j� / Property Line 0 SEEPAGE PITS Ej Depth Size Number t SUMPS L Distance to nearest: Well Foundation Property Line _ DISPOSAL PONDS t�L,1 L. 7 Ivb/ ^( �L tsw{t_ G cyy� 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. 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 shall not employ any person in such manner as to become subject to workman compensation laws of California." r. 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 compensation laws of California." The applica t t call r all_re irc� ed inspections. Complete draw, g on reverse side- Signed ide- p Si ned x (/��C/.�--�►-�— Title: a rf.��.n� Date: .[l`�j O-3_ 0 PARTMEt S[ ONLY n Area "5 Stk 466-6781 Application Accepted by (.__ Additional Comments: Lodi 369-3621 Pit or Grout Inspection by �IiealthPermit/Services Date EJ Manteca 823-7104 Final Inspection bf�j �/,�� Date .:T-2_5:e5 Tracy 835-6385 Applicant - Return all crpi Lo: Envir lent 1601 E. Hazelton Ave., P.O. Box 2009, Stk., f,A 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT Nn I INFO r , ii 13-24 RE`:. 11-26 '•� �1--� I