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APPLICATION FOR,PERMIT r SAH JOAQUIN LOCAL HFALTH OIS(RICT e �`��• 601: HAZEL70N AVE'., S-OCKTO'•I, CA ., Telephore (209) 466-6181 PERMIT 40, + r ?ERMTT EXPIRES_1 YEAR FROM JAIE ISSUED D4[E IS511E0� (Complete.in Triplicate) Application is hereby made -'to the San Joaquin local Healt,; District for a permit to construct and/or install the work herein described. This application is !rade in compliance with San Joaquin County Ordinance No. 549 for sewage Or No. 1861 for well/puirp and the Rules and Regulatioqs of he San Joaquin. Loco �h,e/��lth District. Job Address !ter d�.L $U division Pare Owner's Nan ess— Contractor's ha . ` ' `"= — Phone - ti License NO. z _•�.� Phone TYPE Of dE L x "�' A&Addr r, ••• L /PJMP MORrC: NEi( WELL• + .WELL R' EPLACEMENT ❑ 'L`) 4NESTF.UCTJON ❑ ' PI;T"P INSTALLATION j]' • r OTHER:- V SYSTEh1' REPAIR .. ' DISTANCE TO NEAREST: SEPTIC TANK V L `, ❑ + --- SEWER LINES',,, DISPOSAL FLD. PROP,'LINE FOUNDATION ! , _,;7"" — — - _ + _AGRICULTURE FIEL'L� OTHER llELL PITS/SUMPS +d„� INTENDED USE TYPE\0F M'ELL % PROBLEM AREA C NN� GQNSTRUCTION SPECIFICATI % _ i ❑ Industrial ❑ Open Batton (1 Manteca— _Dia, of Well Excavation ❑ Domestic/Private Gravel Pack (� Tracy r Dia, of. Well Ca?;in Public r , s:. 9- �j Other [],Delta �*^ Irrigation -' Type of Casing Approx. [� Eastern S Cathodic Protection Deptri r .t _ Speciflcations - 0 Geophysical ; - .' Depth of Grcut. Seal ❑ Other ; + Type of Groul -� ' ,Surface Seal:•Installed by _ Repair Work Cone [ Type of `Pump M'.�. It. P. State Work Done Well Destruction �;) We11-Di.aireter , i ��Sealing Material (t—'o 5o',j• _ Depttrl:, ! Filler Materlal-(Belowi50') -� TYPE OF SEP' IC iJGP.K: NEW INSTALLIATfON` REPAIR/,4DDIT;ON { * (P!Q.kptic tank or seepage pit permitted if public sewer is !' ' Vii• " U •' -`a� aV Ilab within 100 feet.) Installation will serve:. Residence Commercial %; Other 'f� r W um er of living units: humber of drooms Lot size ep3 Character of soil to a th of eet: f` '✓t' _ fl�14�ater table depth �� + SEPTIC TANK Type/Mfg = Capacity '(fQ(�1p„IhID. Cor.ipartments PKG. TREATMENT PLT. ne/Mfr- _�' �^' r - -�-- ❑ Y! _ Capat'ft-, Method of Dispos�j SEWAGE SYSTEM Distance to nearest: Well r — - ' --- DESTRUCTION ❑ M&L Foundation T� ! Property Line LEACHING LINE ❑ No. & Length of lines -_ _ Total length/size - FILTER BED ❑ Distance to nearest:. 11 Well Foundation Property line SECPAGE PITS (-.I Depth ' 4 Size r Numb er SUMPS ❑ Distance to nearest: 1Wellw Foundation property line DISPOSAL PONDS j ice_- ' - '-- , I hereby certify that I have prepared this applicatio!i'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 I-ealth District. f : Louie owner or licensed agent's sigrature certifiesthe.following; "1 certily that in the perfo mince of the work,fbr, which this permit is issued, 1 shall not employ any person in such mariner as to become ssniuhject to workcomoensatioen laws of California." Contractor's hiring or sub -contracting signature certifies the following; "1 certify that -in -the -performance -of work for which this permit is issued, I shall eriploy persons subject to wofknan's coiper,sation laws of California," The ap•pli:ant m st ca 1 t' al required inspections. Complete drawing on�t c r c Side. C Signed X— - Title:_ �1f{ r. 1 _ _ R --_____-- Cate: � ..•, OR/D PART PIT LSE ONLY Application Accepted by . �_— -- Area t :-. r �( Stk.. ,•x..-466-6181 Additional Comments: Lodi 369-36"21 Pit or Grout Inspection t — _ Date _ J Manteca 823-1104 Final Inspection by Date_4-- L ] Tracy 835-6335 Applicant -Return all copies to: Environmentaliik--ealth Permit/Services 160 _. hlaze)ton Ave „ P.O. Dox 2009, Stk., Cr 9520; f FLE BASE A10UN1 DUE- - AMOUNT REMITTED RECE11'EJ 3Y DAIE FERMI' NC. :NFOLH 13-24 REV. 10/87 14-26 10/92 500