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f _ E APPLICATION FOR PER.V'IIT SAN JOAQL•;" LOCA! H"LTH DISTRICT E I601 E. HA7ELTDN AVE., STUCKTON, CA PERMIT NO. �� Telephone (209) 466-6781 GATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED.. (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 wel3/p6mp. and the Rules and Regulations of the S Joaquin Local Health District, b Address 7 $ Subdivision Name Owner's,Name r Phone J1 Contractor's Name License No. phone Q TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT -DESTRUCTION . PUMP INSTALLATION SYSTEM REPAIR { OTHER' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE -.FOUNUATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ' TYPE OF WELL ._ PROBLEM-AREA k CONSTRUCTION SPECIFICATIONS ` Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private Gravel Pack Tracy Dia. of Well Casing Public F-1 Other Delta Irri Type of Casing 9 Approx. Eastern 4 ation ADepth Specifications Cathodic P_rotect.ion p `^Depth,,of Grout-Seal" - --^� - '�:L—)Geophysic4aI k Type of Grout Other '. + } i�..P- - �. Surface Seal Installed by 14 Repair'Work 0one Type of Pump Fy_, H.P. State Work Done wh'l .Destructioh U Well Diameter` wSealing Material (top 50') { p n Depth Filler Material (Below 50') w v t TYPE OF SEPTIC WORK: NEW INSTALLATION ' I. REPAIR/ADDITION (No septic tank or if L p public sewer is available within 200 feet.) ! Installatidn will serve:--Residence Commercial _ Other Number of living units:=' Num�,of .bedrooms Lot size Character of soil to a depth of 3 feet:` Water table depth SEPTIC TANK ® Type/Mfg } i Capacity No. Compartments ! PKG. TREATMENT PLT. Type/Mfg •"`_ -^ -Capacity - Method of,.Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION I] r LE LINE No. & Length of lines Total length/size V FILTER BED ^^- 0- cpistance to^nearest: WeTJ Foundation Property Line v SEEPAGE PITS Depth Size N be -76 j' SUMPS t �,.� Distance to nearest: Well ��'} Foundation Property Line DISPOSAL+FONDS i7` r I hereby`certi-fy,that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state maws, and rules and regulations of the San Joaquin Local Health District. Home owner•cr 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 applican m st for all r, qu'red inspection Complete drawing on reverse side. k_ Signed X' .. ' '�fJ: �� . Title: �_ aA � Date: / F,�#2701ENT USE ONLY�— Application Accepted by . C�� Area Stk 466-6781 L ``/ Additional Comments: l Lodi 369-3621 Pit or Grout Inspection by �/Jjl Date Manteca 823-7104 Final Inspection by J Date L Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 � I FEE BASE AMOUNT DUE AMOUNT REMITTED ,RECEIVED BY DATE PERMIT NO. INFO L- to EH 13-24 REV` 10/82 10/82 500 14-26 k- 7