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G APPLICATION FOR PERMIT SAN JOAQUIN.LOCAL HEALTH DISTRICT PERMIT N0. 1601 E. HAZELTON AVE., Telephone,(209) 466-6781 CA DATE ISSUED PERMIT EXPIRES 1 YEAR FROM-DATE-ISSUED , (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for 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 well/Pump N and the Rules and Regulations of the San Joaquin Local Health District. .."Subdivision'Name Job Address Phone Address Owner's Name . License No. Phone Contractor's Name -r TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATIONSYSTEM REPAIR OTHER 0 DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL _INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION5 ID Dia. of Well Excavation Industrial [ Open Bottom ❑Manteca pia. of Well Casing U Domestic/Private �Gravel Pack Tracy Public G Other E]Delta Type of Casing U Irrigation Approx. Eastern Specifications �] �Q Cathodic Protection Depth Depth of Grout Seal Geophysical - -Type of Grout D Other , . _ w�- -�.^ -^ - , i """.Surfac`e,!*�eal Installed by Repair Work Done�Q-•^-•Type of-Pump°-�-• Hsps -State York Done -o�-,- -M� Well DestructipFI Well Diameter _ Sealing Material (top 501) k # i Depth Filler Material (Below 50') = i TYPE OF SEPTIC WORsewer K: NEW INSTALLATION REPAIR/ADDITION E] (No septic tank or'seepage p�ava}lableewithinrmitd ifu200cfeet.) 7s Installation will serve: Residence -0n�nercil r O her �/ �� ' �, ' Number Of'l�iwing units; _� Number of bedrooms Lot size- "?� t _ P + A ©�� „�:: Water table'de th Character of soil to a depth of 3 feet: H - Capacity ,0�,�— No. Compartments , SEPTIC TANK Cj Type/Mfg _ . _ Y+T- �,.. Capacity �'MetYind of"'Dispo's�l PKG. TREATMENT PLT: n TfYPe/Mfg J 'T� � Foundation�� Property Line' SEWAGE SYSTEM Distance to nearest: Well �- $ DESTRUCTION Total length/sizes t No. & Length of lines - LEACHING LINE] 1 i y 4 Foundation, Property Line's 4 t FILTER BED ❑ Distance to nearest: Well Depth /, ,� Size , Number SEEPAGE PITS �I p _ [L� 'r � property Line - AQ^.ter• Distance to nearest: Wel] rd4 P Foundation° + - SUMPS ,l y3 4 DISPOSAL PONDS ' hereby certify that 1 have prepared this application and that the work will be done inaccordancewith San.Joaquin county I ordinances, state laws, and rules and regulations of the San Joaquin Local Health District:' t Home owner orlicensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not emp1ay any person in such manner as to become subject to workman compensationilaws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work far which this permit is issued, I shall employ persons subject to workman's compensation laws of California."} 4 The applicantimus cal orrequ' inspections. Complete drawing on reverse side. Date: Signed X { Title: FO EPARTMENT USE ONLY _ `7 Stk 466E]- 66' 6� -6181�� Application Accepted by, /fi t Area �•( �:.,, _ a„, odi 069-3621 Additional Comments: 0 Manteca1823 7104 Date ° i Pit or Grout Inspection by Date � '; L Tracy i83-6385 i• Final Inspection by �-.? t Applicant - Return all copies to: Environmen Health Permit/Services 1601 E. Hazelton Ave , P.O. Box 2009; Stk., CA 9 } ] PERMIT NO. [FE O 'BASEAMOUNT DUE AMOUNT REMITTED REC€IVED BYDATE- p. o .. r; �«� ° `_ ' _.,-...,.....-«a -•---=10%82'500 --.- .- 'EH 13-24 'RSV: 10/82 [ 14-26