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A APPtICAT10N FOR,PERMIT ` s SAM JOAQCiN LOCAL HEALTH OiSfR1CT `��• ' + .601 :. HAZELTON AVE., S`OCKT0% CA PEN N_ O �.,xn ., Telephore (204) 466-6781 + HERMIT EXPIRES I YEAR FROt1 vAIE ISSUED DAIS ISSUED y iC0mplete-in Triplicate) Application is hereby made' -to the San Joaquin Local Healto: District for a permit to construct and/or install the work herein described. This application is rade in compliance with San Joaquin County Ordinance ho. 549 for sewage or No. 1861 for and the Rules and Regulatfo s of he San Joaquin. Loca H lth District. welt/pump Job Address Owner's Nan " v Su division yare Address w /��y(/r��-/f,' Phone Contractor's ha, ' - - "-4' 4q�•6�+�'� CI License No., .2 :? "7 t.� Phone TYPE OF riELL/DUMP WDRK: NEI! WELLS CQi t ' ' { ` WELL_REP�ACEMENI L J-DESTRUCTI0N I_I "PUMP` ISTALLATIONSYSTEM'REPAIR DISTANCE 70 NEAREST: SEPTC TANK ` V L� � �• O1}ER,•�•'" --- _ SEWER LIAESn� _ DISPOSAL FLO. PROP AI NF _ �\ FOIAVD1iIbN r AGRICULTURE 11ELL� _ OTHER iELL _ _PITS/SUMPS r INTENDED USE iC TY,-i4 WELL pROBLEA AREA G'%� -ONSTRUCTION SPECIFICATIO'l5 f Industrial •❑ Open Bottori jManteca Dia, of Well Excavation _ Domestic/Private r U (_] Gravel Pack [� Tracy , Dia, of,Well Ca#ing - Pub] f c G Other `V Irrigation ,�•Oe�ta Type of Casing Approx. [� Eastern S Cathodic Protection Deptr? _, i*ivcations - Geophysical ; —4V l0eptth of Grolit. Seal " Other ►''Type of Grouf - _.- t Surface S@0%,nstalled by _ Repair Work,Donc Type of "'�Il.� - [[ YP pump - P. ,State kbrk Done _ f Well Destruction (1D We.11*. 'Dt.a7ter i 'is5ealing Material (tbp X0',7• `^- - De'pth'+.r y Filler Matef•1al-(Be1 TYPE OF SEP'IC WORK: NEW INSTALL7AT[ON <R AIR/ADDIT'.ON t •;•(Nq.septfc tank or seepage pit permitted if public sewer is * s av ifab within ?DO feet.) installation will serve:. Residence _ Connfercial 1 "Other�fb_ ,�pn� •� humber of living units: r. humber of Brooms -" "i ' Lot size_ ~ �" Character of soil to a pth of 3 eet: ater table depth SEPTIC TANK Type/MFg / e� Capacity Q (,i C D. Compartments - PKG. TREATMENT PLT. 'ype/Mf, '""'""""�"'" " rZa acit "" --- 4 p J Method of Disposal - SEWAGE SYSTEM � '- — • �- -- -- Distance to nearest: Well �� Foundation j� Property Line DESTRUCTION �_ AIL-_ _ LEACHING LINE U No. & Length of lines - ^ Total length/size- FILTER BED (] Do nearest:. Well Foundation Pro:)eri istance t 4 y Line SECPAGE'PITS ra Depth ' 4 Size + - Number _ - --- - - - - SUMPS ❑ Distance to nearest: Well _ , z" Foundation Property line DESPOSAL PONDS I h6reby certify that I have prepared this application'and that the work will be done in accordarce with San Joaeufn county ordinances, state laws, and rules and regulations of the'Sar) Joaquin Local I•ealth District. I+ome owner or licensed agent's sigrature certifies the•following:,"L certily that in the Perforr+ance of the work.fbr.which this permit is issued, 1 shall not employ any person 1n such mariner as to become subject to workrm nt comoonsation laws 'of California." Contractor's hiring or sub -contracting signature certifies the+followiny: "I certify that-fn-the-performance•or'the*work for which this penr.fL is issued, I shall er+ploy persons subject to w k+ian's compensation laws of California." The applicant m st ca 1 t' all required ins cctions. Complete dray+Ing on/�e r c Side. Signed X- _c _ Title: _j rrF ----- Date: - -' /J ORD PAR .NT LSE ONLY �a Appl icaL on Accepted by , _- _ Area r ---:� / _,.-.-r...(-.-I-Stk.. ,,,.._4664781 + Additional Comments: Lodi 369-3621 Pit or Grout Inspection _ _ _ Date _ J Manteca 823-1104 Final Irspection by -i --Date- . �'} Tracy 835-6335 Applicant - Return all copies to: Environmental kealth Permit/Services 160 E. 9lazelton Ave., P.O. Box 2004, Stk., CA 95201 FEE BASE AMOUNI DUE As'OUNT REMITTED RECEIVE) 9Y i- CAW- PERv[- NO. NFO -- -- `--�--------•-------I EN 13-24 REV. 1,D/8? 14-26 I r�V W