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r 2 APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DIS I- 2 1601 E. HAZELTON AVE., STOCKT N, CA S�p 3 PERMIT NO. '$v' Od7 Telephones(209) 466-6781 DATE ISSUED 3 PERMIT EXPIRES 1 YEAR FROM DATE ISSE,,3 1.7 1A WN LCCAL� (Complete in Triplicate), HEALM DIsTRIC Application is hereby made to the San Joaquin Local Health District for a permit to constructand/or install the work herein ✓ described. This application is made in compliance with San Joaquin County Ordinance No. 5491fcr sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �{� _ �;� � rntar3Subdivision Name Owner's Name Address Phone 19P- �5r Contractor's Name w License No. �_s . Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS C�, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS o' ❑ Industrial f—I Open Bottom E Manteca Dia. of Well Excavation �l ''-��-`�U�Doinestic'/Pri•vat�� =-�Q Grav�1`Pac•k��iracy"^��• =��'�-�Dia`=of�WeTl-0asing- �_- =___�¢-_ - — _-=•�...:,=.�._ a.-.- ❑ Public ❑ Other D Delta T Irrigation A Type of Casing LJ 9 Approx. ❑ Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal - ❑Geophysical Type of Grout Other Surface Seal Installed by Repair Work Done El Type of Pump H.P. State Work Done r �1 Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') b'-x TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/.ADDITION F❑ (No septic tank pit permitted if public sewer is f/ � avai l}e wi h'n 200 feet,) yV/ Installation will serve: •Rersi/d�en�ce _ Commercial ✓ Other ( / � / Number of living units: Number of bedrooms Lot size Z l� E Character of soil to a depth of 3 feet: r Water table depth �1 SEPTIC TANK Type/Mfg Capacity 14,06 No. Compartments " PKG. TREATMENT PET. ❑ Type/Mfg Capacity Method of Disposal, SEWAGE SYSTEMDistance to nearest- Well , Foundation Property Line O f' . A. DESTRUCTION ❑ LEACHING LINE "No.- & Length of lines '- - r p t:_ Total length/size Zoo K Z! FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size 's Number SUMPS ❑ Distance to nearest: Well Foundation Property Line OI S. OSAL.PONDSt, ❑I ; - ,... - a: =,K•�= I hereby certify that 1 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 workmanS 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 subject to workman's compensation laws of California." The applicant ust call fo�11 equirgd inspections. Complete drawing on r Terse �ide. Signed X r u Title: J •F Date:_ _ ARTMMT E ONLY f� Application Accepted by Area —C/ tk 466-fi7B1 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by AO Date ❑ Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all copies to: Environmental Health P it/Services 1601 E, Hazelton Ave., P,O, Box 2009, Stk., CA' '95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. 11 INFO If EH 13-24 REV, 10/B2 10/82 500 14-26