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APPLICATION FOR PERI'iT S4N JOAQUiN LOCAL HEALTH :7iSTRICT 1601 E. HAZELTON AVE., STUCKTON, CA PERMIT NO. Telep'hane (209) 466-6781 ' 1. �p PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED 0 (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 described. This application is -made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, / 1 Job Address J/ G „fj �,� 57 r/iSubdivision Name. t Owner's Name Raj„- PA=Z_J=- _ Address ZqV4C Phone FW 7 Contractor's Name• ,=Ze V;�% 6-7, &MpD License No. 442,reX7/6 Phone l;,*4'-322/ TYPE OF WELL/PUMP WORK: t NEW WELL WELL REPLACEMENT .C DESTRUCTION -PUMP'-INSTALL-A-hON-E-^----SY:ST,EM-REPA-IR�--U- —OTHER U , w1CJ DISTANCE'0 NEAREST E: SEPT{L TANK <• SEWERwLINES. _ ` lam, DISPOSAL FLO. PROP, LINE V" { J _ +e ,FOUNOATION AGRICULTURE_14ELL ,OTHER WELL PITS/SUMPS ,. INTENDED USE .+ � 7;Y�E!'OF_WELtfPROSLE% AREA et CONSTRUCT ION"SPEC IFICATIONS T. 117 Industrial r t F-'4en_"$6ttom—f�J-Manteca' ;l Dia_!of Well"Excavation U oomesticJPriv Gravel Pack �''�[ Tracy . fi Dia.'of.Well Casing !] Public i Et] Other x ' Delta y by Type of Casing ' V Irrigation Approx. Eastern ❑Cathodic Protection Depth ?' Spec ificatianI� � Depth of Grout Seal , I❑Geophysical i Type of Grout ' U Other € s Surface Seal Installed by jRepair Work Done F-! Type of Pump y�`c H.P. i '7 '. State Work Done .Well Destruction ❑ Well Diameter 1 ': Sealing Material (top 5o') _ -Depth " is Filler',Material' (Below'50') TYPE OF SEPTIC WORK: NEW INSTALLATION Lj REPAIR/ADD'ITION0(No septic tank or seepag�pTt-permitted if public sewer is avai,l,ab�l'e-wtthin 200 feet.) Installation will serve.: Residence _ Commercialy'Zotherr r J t Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: _ I f' Water table depth ! .y SEPTIC TANK .A Type/Mfg Capacity 12-092 No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal s SEWAGE SYSTEM Distance to nearest: Well Foundation �°_ _ Property Line .1 DESTRUCTION y LEACHING LINE rA. & ength of lines Total lenqth/size FILTER BED Distance to nearest.:', Wei L; Foundation Property Line SEEPAGE PITS LL< Depth / size '46g Number SUMPS j_! Distance to nearest: Weil ::.�. Foundation � 'Property Line 't" . I -7 DISPOSAL PONDS CI IV A 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 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 must call for all required,3inipections. Complete drawing on reverse side. Signed X 4 Title: s Date: A -D EPARTMLNT.�USE_ONLY!_�.,,,.,F Application Accepted y _ Area [ :.5tk 466-6781 _ Additional Comments: 11 k- Lodi 369-3623 Y Pit or Grout Inspection by.- 17 Date .:�. ,tom Manteca 823-7104 f Final Inspection by Date Y/Z- Jia ❑ Tracy 835-6385 Applicant - Return all copies to: ,Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 45201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT ND. INFO �" - 2 3-131a EH 13-24 REV. 10/82 $ 10/82 500 14-26