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':APPLICATION :FOR,'PERMIT SAN JOAQUIN LOCAL HEALTH DI ICT .160'1 E";HAZE1_-=rO . ° Cf Telephone (209)466-6781- - PERMIT EXPIRES TYEAR FROM DATE ISSUED �� r3�1 pt)N�G�S {Cofrtplete !in Triplicate) , c,RC� c pt,T S 11V1�10� �3 111Ei��1 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install: work herei`,�-,}�6 �k�$application is I made in compliance with San Joaquin County Ordinance'No.549 for sewage or No. 1862 for wet)/pump and the Rules.at4AAtions of the San Joaquin i Local Health District. Gila Al :.i w Z Job Address 3 2 Zf 6 VA l �Q IEf`?o Ill't I. 5 1 =i City 5 ;O Lot Size:1 0. D a o r�� PM -, rJ � Owners NameCrr��a� fl. S•A• INC `'1 Address SRa Qg.a+fON CH 9 �s$3 Phonb4Is $�}2�9625. , 6Z 6 -i SJ7o N fizz. _ y _ �. r� i Contractor f � WIEt.i'I�Q14+r1nr6Addressc'oNCA� A 9�Sf $ Licenseho'.482 �� Phoiltf�5 685- C6f.3 ' TYPE OF WELL/PUMP: NEW WELL w WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION O +' "SYSTEM REPAIR- ❑ f `"' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK loo 18EWER LINES 5� DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE!WELL : OTHER WELLPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia`. of Well,Excavation O.5 1 h Dia. of Well Casing ❑ Domestic/Private Gravel Pack - ❑ Tracy Type of Casing C Specifications D•of0 >101- c- 101- N ❑ Public " " fa,O her VQ Delta Depth of Grout Seal 6� Type of Grout e� K bt []r, i.,. ! I 19'rlauti Dnp t3v�Apprax, pepth I'i Eastern SuHaee Seal Installed by KNIt.Nflef leao WPortc Done ❑ Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Mateiial (top 50') Depth a Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l I.-REPAIWADDITION I I DESTRUCTION 1.I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_' Commercial_ Other Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfgi Capacity No. Compartments d PKG. TREATMENT PLT. ❑ '' � r_. .� Method Of'Disposal ell Foundation Property Line - �- i Distance to nearest: ;,. l i N I. LEACHING LINE ❑ No. & Length of lines:r °f Total length/size FILTER BED ❑ Distance to nearest: "4�'jiv4u :F" Foundation Propany Line f SEEPAGE PITS I I DepthSize ,z = P _ Number 1 SUMPS Ll Distance to nearest: I,'.- .Well Foundation Property Line DISPOSAL PONDS I-) 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's compensation laws of California." Contractor's hiring or sub-contracting signature - certifies the following: "I certify that in the performance.ol the work for which this permit is issued,i shall employ persons subject to workman's compansa- tion laws of California." 't The applicant mus II all requ d inspections.'iComptete drawing+on,reverse side, Signed X .Title: " Qo 1� Date: I 4k �99`t7 4 FOR DEPARTMENT USE ONLY Q ,. o� L, t Application Accepted by Y ''r Date " � Area� 7 1' Pito au Inspection by '. _ 11 ��:Date- � Final-inspe tion-by _ Date •!3 Additional Comments: '_ l "� "' ""�_-' t7r L44 ❑ Stk 466-6781 Cl Lodi'"i 369-3621 ❑Wanleca 823-7104 ',` ❑ Tracy 835-6385 Applicant - Return all copies-to:!Environmental Health Parmit/Services-16012(x _ E. Hazehon Ave.,P.D. Box 19, Stk., CA 95201 4;. s _ ti I FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO a EH 13-24 IREV.I/x 51 'f' C ., EM 14-26 171 p. i '- .�. .. ! 911- � * ..`.� �•' . .. ..I