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7 ItAPPLICATION FOR PERMIT NOV - . / a SAN JCAQU LOCAL HEALTH DISTRICT V 1601 E. HAZEL,70N AVE., STOCKTOr iN ` PERMIT NO. $3-1aS Telephone. f��{209) 466L6781 QUIN LOCAL + PERMIT EXPIRES i YEAR FROM DATE ISSMU['T LTH DISTRICT DATE ISSUED (Complete in Triplicate) +. Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or .ins tall 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. Job Address 21242 E. CopperopoliS Subdivision Name Owner's Name DeT nis Bekker Address Same Phone Contractor's NdmeMoormans Water SyStlJ11M,%e No. 267695 Phone 931-3210 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION F PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTA-G•TANK . SEWER-L-d"NE•S "-L�r mm i"SPOSAL FLDc:*�.-�..-�;... PROP. LINE FOUNDATION AGRICULTURE WELL OTHER 14ELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS } 1 Industrial # ❑ Open Bottom L] Manteca Dia. of Well Excavation U Domestic/Private Q Gravel Pack L] Tracy Dia, of Well Casing rn� Public S Other Delta Type of Casing ; v i Irrigation Approx, Eastern Vv [ Specifications Protection Depth p Geophysical Depth of Grout Seal ' �..f , Type of Grout Other } Surface Seal Installed by Repair Work Done Fi Type of Pump sub H.P. 2 State Work Done replaced pump Well Destruction ❑ well. Diameter Sealing Material (top 50') Depth Filler Material (Below 50') ,TYPE OF SEPTIC WORK: NEW INSTALLATION LIREPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is F' Installation will serve: Residence_ Commercial Other available within 200 feet.) 4 Number of living units:i Number of bedrooms Lot size Character of soil to a 'depth of 3 feet: Water table depths SEPTIC TANK Type/Mfg Capacity No. Compartments ,, PKG. TREATMENT PLT, ❑ t Type/Mfg Capacity Method of,Disposal f'�4 SEWAGE SYSTEM /" Distance to hearest:�rWell .� Foundation. Property Line - DESTRUCTION ❑ - — ✓.,r�r " LEACHING LINE ❑ No. & Length of lines r✓* Total length/size ! .FILTER BED Distance to nearest: We " ounda'tipn�� Property Line ' f SEEPAGE PITS f_j € Depth Size"*) Number SUMPS LI Distance to nearest: Well Foundation + Property Line, DISPOSAL PONDS �� ;y ► 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 HealthiDistrict. 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, Iishall employ persons subject to workman's compersation laws of California," The applicant must call for all required inspections. Complete drawing on reverse side. Signed X f7An �rd , yn� Title: . Date: 1-FOR E MENT USE DNLYApp katio - _Area Stk 466-6781 Additional-Comments: __._ /.—____ _ .--Lodi 369-3621 Pit or Grout Inspection by ' Date ❑ Manteca 823-7104 Final Inspection by / Date /1//S o f' ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Heb th Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 � r, FLE BASE AMOUNT DUE' .t AMOUNT 'REMITT-ED S 4:" RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26 i