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APPLICATION FOR PERMIT y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 o.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. vs�� e_bF_S �Q V Job Address Parcel #243210 City Manteca Lot Size PM Owner's Name Oliver Pizzi Address 10301 E. Mof fet Blvd. ,Manteftane 823-6031 Contract,purviance Drillers Alma P. 0. Box 64,LindEU1cense No. 377923 Phone887-3554 TYPE OF WELL/PUMP: NEW WELL:K WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D 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 El Industrial El Open Bottom El Manteca Dia. of Well Excavation 16 Dia. of Well Casing 16 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing steel Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal —0— Type of Grout _ X Irrigation 2 rJ_0_�pprox. Depth I I Eastern Surface Seal Installed by _ (� Repair Work Done D Type of Pump H.P. State Work Done new Well Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well— Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. 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's 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 compensa- tion laws of California." The app75��.4 ud inspections. Complete drawing on reverse side. Signed Title: President Date: 10/14/88 F, DEPARTMENT USE ONLY (� Application Accepted by ��:_ — ^ n teuv .Ary, Date ,�1� Area "` 5 Pit or Grout Inspection by 2!5�� Date 41 a-, Final Inspection by Date Additional Comments: 4i D Stk 466-6781 O Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835_ 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEINFO T DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. +.EH 14.241REV,iiH�l EH 14.28