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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PERMIT NO. /� 1601 E. l HAZELJON AVE., STOC6781 , CA v Telephone (209) 466:6781 DATE ISSUED 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) San Joaquin Local Health District for a permit to construct and/or install the work herein Application is hereby made to the S 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. Subdivision Name + Joh Address Phone Owner's Name �,�R-[tL Address ?hone r 1 Contractor's Name + License No. W WELL REPLACEMENT ❑ DESTRUCTION ❑ h TYPE OF WELL/PUMP WORK: NEW WELL L] ❑ "� ❑ SYSTEM REPAIR ❑ OTHER PUMP INSTALLATION DISFOSAL FLO. PROP. LINE DISTANCE 70 NEAREST: STANK .__ FOUNDATION OTHER WELL SEWER LINES I PITS/SUMPS ATION AGRICULTURE WELL ---- ,'/ PROBLEM AREA CONSTRUCTION SPECIFICATIONS � t INTENDED USE TYPE OF WELL Dia. of Well Excavation s �4 0pen Bottom ❑ v^ Industrial Manteca Dia. of Well Casing I❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ❑.Public ❑Other ❑ Delta Type of Casing %A 111 A rox. Eastern Specifications " irrigation PP Depth '6epth of Grout Seal F-1CathodicProtection , d, ❑Geophysical Type of Grout: Other Surface Seal Installed by " Type of Pump H.P.Sealing Material (top 5p')State Work Done i Repair Work Done ❑ yp ` Well Destruction ❑ Well Diameter � Filler Material (Below Depth / TY ❑I REPAIR/ADDITION ❑ (No sept'i.c.tank or seepage PE OF SEPTIC WORK: NEW INSTALLATavailable within 200 feet.) pit permitted if public sewer:. is r Installation will serve: Residence &/ Commercial Other =- table depth 1ze Number of bedrooms — Lot=s- f $ Number of living units: _J— Water lE Character of soil to a depth of 3 feet: �i� No. Compartments i M Type/ fg L' Capacity Sf SEPTIC TANK Capacity t .Method of'6i5posal � � PKG. TREATMENT PLT. ❑ Type/Mfg 'Property Line �_� SEWAGE SYSTEM Distance to nearest:. ldell "f" � > DESTRUCTION Q 1� Foundation LEACHING LINE - No. & Length of lines . »� Total length/size Foundation Size �0 Property;Line s r FILTER BED ❑ .. Distance to nearest: Well � e CkSize °f Number z ; SEEPAGE PITS ' Depth ——F PropertyLine SUMPS Distance to nearest: Well Foundation w. LI ' DISPOSAL PONDS ❑ 1 r: A ance I hereby certify~that I—have preparnd re,ulatponsaof thenSanhJoaquinwork LocalsHealth DistriictdwofhthenwoorkQuin for whichthis ordinances, state laws, and rules a 9 t Home owner or licensed agent's signature certifies the following: "I certify that in t performance permit is issued,nI shall ncontract�ngnsi9naturelcertifiesnthe followner as to ing meiscertify ubject tthat rinathecperformance ofwthe fwork�for nwhich f Contractor's hiring or I .this permit is issued, I shall employ.-persons subject to workman's compensation laws of California." iii lica�nt must calK ,U`l'required spections. Complete drawing on reverse side. 1 Date: The app Title:Signed XFO DE AFCTMEN USF ONLY5tk 466-6781 AreaApplieafioniAcy ❑ Lodi 369-3621 Add Tonal Comments: Date r g y ❑ Manteca 823-7104 Pit or Grout Inspection by i ❑Date Tracy 835-6385 Final Inspection by F �, Applicant - Return all copies to: E vironment Health Permit/Services 1601 E`: 4iazelton Ave., P.O. Box 2009, Stk., CA 95201 RECEIVED By BYY,sfpERM1T,Np. FEE BASE ff AMOUNT DUE AMOUNT REMITTED . { r INFO yj `7 10/82 500 EH 13-24 REV. 10/82 14-26