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C/- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISI AICT N i 1601 E. IIAZELTON AVE., STLiCKTON, CA Telephone (209) 466-6/81 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Josquin Local H hh District for a permit to construct and/o1 install the work herein described.This application is 1 reads In compliance with San Joaquin County Ordinance No.549 for sowsoe or No, 1882 for.yell/pumr,and the Rubs and R•roulaGons of the Sen Joaquin _ Local Health District. Job Address _J-900_�_-.�f �e 1-_I"^ • - City-.!_,�O�tom_ Lot Llie_L Z acre- PM Owner's Nartw Crowns L cLR�Address -��]({I( -tI"pa� Phare /W Contractor._ r I Qf�-�f,'�-- dress _5 a me license No. Phone_ TYPE OF WELL/PUMP: NEW WELL (A WELL REPLACEMENT fl DESTRUCTION O PUMP INSTALLATION I SYSTEM REPAIR LI OTHER C1 ;� f DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES DISPOSAL FLD.- PROP. LINE,: FOUNDATION AGRICULTURE WELL _ OTHER WELL--- PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (7 Industrial O Open Bottom ❑Manteca Dia. of Well Excavation_ Uis. of Well Casing ❑ Domestic/Private ❑ Gravel Pack O Tracy Type of Casing __ Specifications F?Public 1.1 Other LJ Delta Depth of Grout Seal Type of Grout—__- L irrigation __A.pprox. Depth (I Eastern Surface Seal Installed by -- 1 Repair Work Done L1 Type of Fump H.P. State Work Done Wall Destrueti n P Well Diameter __ Scaling Material(top 501 Depth_ ____ Filler Material(Below 501 -_ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION O DESTRUCTION (No septic system permitted if pubic sower is /y1 available within 200 feel) installation will serve: Residence X_ Commercial-_ Other__`_,• H. -._ Number of living units: _I__ Number of bedrooms C9- /� / 1 Chilracter of so'I to a depth of 3 feet: "I-d__-.-__--.-______-._--.---_Water table depth-[/2I/ SEPTIC TANK .'<Type/Mfg _- a- _--._-__ Capacity-JA Q[Z_ No. Compartments _�- PKG. TREATMENT PLT.i l ) ' Method of Disposal _ D{.,tance to nearest: Nell U - Foundation. l?_,-- Property Line LEACHING LINE P,� No. 8 Length of lies Total length/sire _go ---f - �------- � _ — FILTER BED C..; Distbrics to neap st Well.�(�2Q_ Foundation .?ID___- Property line i Y SEEPAGE PITS [I Oeplh -_�QSize .x L'?:_l�lQ.___--. Number -7— SUMPS f.' Distance to nearesC Wn11J�Q0 _ Foundation ��QQ�-__ Property Line >w DISPOSAL PONDS (; _ 1 hereby certify that I have prepared this eppli"bon and that lire work will W done in accordance with San Joaquin county ordinances, state laws, and rubs and regulations of the Sen Joaquin Lo�.al Health District. Home owner or licensed agent's Figoature certifies the following: "I ceruly that in the performance of the work for which this permit is issued, 1 shall not mn employ any pefson in such rrn, its s to become subject to workman's ro-poonsauon laws of California."Contractor to biting or subcontracting iiigtiatuts certifies the following:"I certify that in the porfonnance of the work for wtuch this permit is issued.I shall employ persons subject to workman's cornponsa. tion laws of California." The applicant most call lot all rogypd inspections. Compluts dn rawing urerersi,side. Signed X.__ilO n M -.---- - - - Title: - Vw ,�r--------- --- Dr•Ic. -97 Sign � FOR DEPARTMENT USE ONLY Application Ac ,pled by Date_._ / Area- Pot rea-Pd c� ---out Inspection by - --- -- Date _ __.._-. Final Inspection by _1-1-1 rJ Dal, 5 /3 / Additional Comments: _ - ---- ------- - CJ Sik 466-6781 CI Lodi 369 3621 i: Manteca 823 7104 L 1 Tracy 835:38ri Applicant Return all copies to: Environmental Health Peanut/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., :A 96201 FEES AMOUNT DUE AMOUNT REMI'TED �.H PECEIVE7 3Y DATE PERMIT NO. INFO -----_ _ KL _ //yy�� FN 11 j4 IaIV /(J�� T"7 , ��(��_ / Er i�24