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{ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL H,'-;'LTH DISTRICT 1601 "E. HA2Telephone AVE., STOCKTO66-6781 CA PERMIT NO. Telephone (209) 466-678I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED b- / (Complete in Triplicate)- Application-is hereby made to the San Joaquin Local Health District for a permit.to construct -and/or install the work herein f described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump F and the Rules and Regulations of. the San Joaquin Local Health District. I Job Address /i Subdivision Name Owner's Name Lg"_r Address Phone Contractor's Name License No. / 1�,5'Z Phone -rp :779-72 "TYPE OF WELL/PUMP WORK: NEW WELL � WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ y DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ` PROP, LINE FOUNDATICN AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom Manteca " ❑ Ria. of Well Excavation Domestic/Private �. Gravel Pack ❑ Tracy Dia. of Well Casing Pub1'ic Other ❑ � Delta Irrigation Type of Casing lovL pJ'4 Approx. Eastern ❑ C athodicc Protection Depth Specifications ❑Geophysical Depth of Grout Seal - fJ Other ;. Type of Grout Repair Work Done Type of Pump Surface Seal Installed by pEL7 � `1 ❑ SIJ — H,p, _/C State Work Done Well Destruction ❑ Well Diameter Sealing Material (tap 501) Depth Filler Material (Below 50') WPM TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence _ Commercial Other available within 200 feet.) v0 k Number of living units: Number of bedrooms Lot size I i Character of soil to a depth of 3 feet: Water table depth SEPTIC T ' ❑ Type/Mfg Capacity No. Compartments rn P7J Type/Mfg I Capacity" Method of Disposal SEWAGE SYSTEM Distance to nearest:" Well DESTRUCTION Foundation Property Line ❑ LEACHING LINE ❑' No. & Length of lines Total length/size FILTER BED Distance to nearest: �WeIT undation Property Line SEEPAGE PITS ❑j Depth Size Number x SUMPS ❑ Distance to nearest: Well Foundation "Property Line DISPOSAL PONOS •� ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county "\Y ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. X11 Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which th permit is issued, I shall not employ any person in such is manner as to become subject to workmant compensation laws of California." 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 sub' ct to workman's compensation laws of California." The appli m t all f r all ed insp i s. Complete drawing on reverse side. Signed Title:" Date: 0 P ENT- ONLY O _n Application Accepted by Area (� Stk 465-6781 ' Additional Comments: Lodi 369-3621 Pit or Grout Inspection y Dated Manteca 823-7104 Final Inspection by Date /-&3 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 FEEBRSE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO r EH 13-24 REV. 10/82 10/82 500 14-26