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c. (Complete in Triplicate) i Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein a 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 nd Regulati ns of the San Joaquin Local Health District. Job Address ` d l may.- Subdivision Name Owner's Name A�dress Phone Contractor's Name e iR 7i -yr- �� r�..,� License No. 33T Phone Bill TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I Industrial U Open Bottom Manteca Dia. of Well Excavation $ ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing Public 7-1 Other Del to Type of Casing V Irrigation Approx. Eastern Depth Specifications 7 Cathodic Protection Depth of Grout Seal 1-1 Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done D Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION L REPAIR/ADDITION 1 4f (No septic tank or seepage pit permitted if public sewer is Oman% �Y, available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: —I-- Number of bedroomsLot size ` \ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments X PKG, TREATMENT PLT. Type/Mfg Capacity- Method of Disposal SEWAGE SYSTEM Distance to nearest: Well �r'� / fi Foundation Property Line— DESTRUCTION ineDESTRUCTION LEACHING LINE U No. &`+Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth _Size) °� X % �_ Number, j SUMPS( Distance to nearest: Well Foundation +E 6.R __...__— Property Line-- -- DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San ,loaquin 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 workmant 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 appl' an mu all for arli-�required inspe ions. Complete drawing on reverse side. Signed K , Title: Date: 6 F TMENT U E ONLY Application Accepted Area [] Stk 466-6 1 Additional Comments Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to. nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE j BASE INFO EH 13-24 REV. 10/82 14-26 AMOUNT DUE AMOUNT REMITTED I RECEIVED 8Y I DATE ! PERMIT NO. 10/82 500 a APPLICATION FOR PERMIT ,. SAN 1601 JOAQUIN LOCAL HEALTH DISTRICT E. HAZELTON AVE., STOCKTON, CA ". PERh1I1` NO. 4�: Telephone (209) 466-6781 V DATE ISSU', ED PERMIT EXPIRES 1 YEAR FROM -DATE ISSUED c. (Complete in Triplicate) i Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein a 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 nd Regulati ns of the San Joaquin Local Health District. Job Address ` d l may.- Subdivision Name Owner's Name A�dress Phone Contractor's Name e iR 7i -yr- �� r�..,� License No. 33T Phone Bill TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I Industrial U Open Bottom Manteca Dia. of Well Excavation $ ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing Public 7-1 Other Del to Type of Casing V Irrigation Approx. Eastern Depth Specifications 7 Cathodic Protection Depth of Grout Seal 1-1 Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done D Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION L REPAIR/ADDITION 1 4f (No septic tank or seepage pit permitted if public sewer is Oman% �Y, available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: —I-- Number of bedroomsLot size ` \ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments X PKG, TREATMENT PLT. Type/Mfg Capacity- Method of Disposal SEWAGE SYSTEM Distance to nearest: Well �r'� / fi Foundation Property Line— DESTRUCTION ineDESTRUCTION LEACHING LINE U No. &`+Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth _Size) °� X % �_ Number, j SUMPS( Distance to nearest: Well Foundation +E 6.R __...__— Property Line-- -- DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San ,loaquin 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 workmant 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 appl' an mu all for arli-�required inspe ions. Complete drawing on reverse side. Signed K , Title: Date: 6 F TMENT U E ONLY Application Accepted Area [] Stk 466-6 1 Additional Comments Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to. nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE j BASE INFO EH 13-24 REV. 10/82 14-26 AMOUNT DUE AMOUNT REMITTED I RECEIVED 8Y I DATE ! PERMIT NO. 10/82 500 a