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I,N-3 a APPLICATION.FCR PERMIT w :a SAN JOAQU21 LOCAL HEALTH D,SiRICT 1601 E. HAZELTON AVE., $TOCKTON, CA PERMIT N0. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y , (Complete in Triplicate) s 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 well/pump ? and the Rules and,Regulations of the San Joaquin Local Health District, Job Address FLp 11 Subdivision Name Owner's Name p.4r"zE/� Addresses Phone Contractor's Name License No, l��.f'y7 („ Phone ! �'-. 9,7 W TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION j_f 1 ' PUMP INSTALLATION 'SYSTEM'REPAIR- U OTHER Fj n DISTANCE TO NEAREST: SEPTIC TANK ± SEWER LINES DISPOSAL FLD. PROP. LINE �J, FOUNDATION E .. AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IJ Industrial U Open Bottom !! Manteca Dia. of Well Excavation Ll Domestic/Private Gravel Pack I { Tracy Dia. of Well Casing 17 Public Other . Delta Type of Casing Irrigation Approx. 6 El Eastern ` Specifications ❑Cathodic Protection Depth Depth of Grout Seal Geophysical . . {�Other Type of Grout I Surface Seal Installed by Repair Work Done ❑ Type of Pump, y H.P. State Work Done I � f Well Destruction U Well Diameter Sealing Material (top 50') Depth 4 •"u"Filler Material (Below 50') V TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is r Other available within 200 feet.) Installation will serve: Residence _Y Commercial O ` Number of living units: Number of bedrooms, y Lot size547 X 7_fTD Character of sail to a depth of 3 feet: t {� Water table depth 0 SEPTIC TANK Type/Mfg Q qZ 4 Capacity I-A-0 Q No. Compartments Z PKG. TREATMENT PLT. Type/Mfg f Capacity Method of Disposal SEWAGE SYSTEM Distance to ne es : ;-Well*-�--�-+ Foundation /�` Property Line DESTRUCTION iL�ha LEACHING LINE No. & Length of lines _2_=5"p Total length/size 2.1 FILTER BED Distance to nearest: Well +---* Foundation /r�/ Property Line SEEPAGE PITS Depth A,:(- Size Number Z SUMPS Distance to nearest: Well =Foundation ZQ r Property Line / DISPOSAL PONDS Cj - h I hereby certify that I have prepared this,"applicat"ion"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. 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 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 applicant must call for all required inspecti ns. Complete drawing on reverse side. � ® Date: Signed X. c�iC !� � Title: �w1i'r F DEP ENT USE ONLY Application Accepted by Area 02- Stk Additional Comment Comments: [] Lodi 369-3621 Pit or Grout Inspection by Date Z �3 Manteca 823-7104 Final Inspection by Date - c-3 Y ❑ Tracy 835-6385 h Applicant - Return all copies to; Environmental Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. ' INFO '93-5 LH 13-24 REV. 10/82 10/82 500 14-26