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QF ,.: + APPLICATION FOR.PERMIT, j ' -V SAN JOAQUIN LOCAL,HEALTH DISTRICT 1601 E. HAZELTON AVEc,,%;TOCK70N, CR PERMiT N0. �.. Telephone (209) 466-6781' A E ISSUED PERMIT EXPIRES-1 YEAR FROM DATE ISSU (Complete-in Triplicate) ~S � / 'Application is hereby made to the San Joaquin Local Health District for a permit to construct nd/or install the work herein descr"ibed. -This application is made in compliance with San Joaquin'County Ordinance No. 549 four sJge or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin�Local Health District. Job Address DC7CeLLlEr2 - Subdivision Name. Owner's Name L�/ Address Phone 7 Contractor's Name License No. 4L Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ti PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public . ❑Other ❑ Delta Type of Casing !* Ll Irrigation Approx. ❑ Eastern Specifications ale ❑Cathodic Protection Depth Depth of Grout Seal a I-] Geophysical Type of Grout Other Surface Seal Installed by Repair Work Done E) uu p Type of_.P . K.P. State Work Done - Well Destruction F-1Well'piameter Sealing Material (top 501) i Depth = Filler Material (Below 50') ^ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted- if public sewer is available within 200 feet.) Installation will serve: Residence ( Commercial i Other 1 1 Number of living units: �_ Number of bedrooms mss- Lot size Z Water table depth Character of soil to a depth of 3 feet: 4e2 f7 �p g SEPTIC TANK � Type/Mfg �: Capacity _��cQ�_,_- No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well _ Foundation 1 - Property Line /�d DESTRUCTION LEACHING LINE IVI lV' No. & Length of lines - Total length size / FILTER BED ❑ Distance to nearest: Well Foundation 0!51 Property Line __- Number -~�SEEPAGE PITS ❑ Depth Size SUMPS ❑ R Distance to nearest: Well Foundation Property Line k DISPOSAL PONDS ❑ `V 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 or this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicanymust call f r'1�1—r—eq�uired inspections. Complete drawing on reverse side. m►�. Date: Signed :pp / , Title: 1 FO ARTMENT USE ONL J i tion Accepted/y Area [:] Stk 456-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Tracy 835-6385 Final Inspection"by _ Date -fid c ��❑ -°Applicant-- Return al,) copies to: v'ronmental Health Permit/Services 16D1 E. Haze ton Ave., P.O. Box 2009, 5tk„ CA 952D1 i FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO �} 16/82 500 EH 13-24 REV. 10/82 14-26 ,a ,