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APPLICATION FOR PE: 'T Q 3 f SAN' JOAQUif:' LOCAL HEALTH I I p 1601 E. HR2ELTON AVE., STO CA � `, �� PERMIT N0.-p3 11:;C G Telephone (209) 466-b �'}• - � DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SS D ,� (Complete in-Triplicate) � �� N Application is hereby made to thelSan Joaquin Local Health District for a permi �to onstruct 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. Job Address A{L 74,!V Subddivision Name � Owner's Name Address 8, Q. �^ ( � Phone oZ^ J / �{ Contractor's Name �_— License No. G ]- 7 3 Phone �{(p a -7 �a� TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER U 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES r`DISFOSAL FLO, PROP. LINE ^ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS J INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSd, #] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ - f=Domestic/Private• Gravel .Pack- Trat �"��-Dia: of'Well-Casir ❑ Public ❑ Other ❑ Delta ` Type of Casing V Irrigation Approx. ❑ Eastern Depth Specifications ❑ Cathodic Protection Depth of Grout Seal a F]-Geophysical EJ Other j Type of Grout s� Surface Seal Installed by Repair Work Done e Type of Pump H.P. ,State Work Donerct.r�, }� .Lui2R, I _• �. Well Destruction ❑ Well Diameter Sealing Material (top 50') �• Depth Filler Material (Below'50') LJ °^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 _ Other Number of iiving units: Number of bedrooms. e Lot size Character of soil to a'depth of 3 feet: i Water table depth SEPTIC TANK % Type/Mfg ` Capacity No. Compartments PKG, TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal # SEWAGE SYSTEM Distance to nearest: Well= Foundation Property Line DESTRUCTION `t LEACHING LINE v No. & Length of. line's` Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS Distance"t6 nearest: Well Foundation Property Line DISPOSAL PONDS s ' 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. r Home owner or licensed{agent's signature certifies the following: "I certify that in the performance of the work for which this f 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 applica mus call fo required insp ctions. Complete rawing on reverse side. r Signed X A4itle: _ Date: OR DEPARTMENT USE ONLY Application Accepted by Area W Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection b y Date ❑ Manteca 823-7104 Final Inspection by � Date �B ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2004, Stk., CA 95201 I FEEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. j INFO S 4 aa33 493-5Q(D EH 13-24 REV. 10/82 10/82 500 14-26