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APPLICATION FOR PER,M1T SAN JOAQU111LOCA-_ HLALTH DIS!R 1, 1601 E. HAZELTON AVE., STOCKT ERMIT NO. $'1-�1oI0 Telephone (209) 466-6781 ' 1984y� DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISS�", JOAQUIN LOCAL v (Complete in Triplicate) HEALTH DISTRICT 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 Aaquin Local Health District. Job Address � (rf.1"� r ' {S(LCi jeAl�bdivision Name P Owner's Name Address J' one j _T.j� rA f �, Contractor's Name ugr= License No. C) Phone�t' TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ 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 J I f Industrial U Open Bottom 7 Manteca Dia. of Well Excavation r�, Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing 31 0 Public F-jOther Delta Type of Casing 71 Irrigation Approx. Eastern O M Cathodic Protection Depth Specifications Depth of Grout Seal p � 17 Geophysical V A Type of Grout F-1 Other Surface Seal Insulted by Repair Work Done ❑ Type of Pump % — H.P. State Wor Done L" auL*i ® Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') T TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is ✓ available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS CI 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+; 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 ust cal all required inspections. Complete dr ng o reverse side'. Signed X �1 � d��rgQ40� Title: 1Date: • R DEPARTM T ❑ Application Accepted by U5 0 V rea Stk 466-6781 Additional Comments: E] Lodi 369-3621 Pit or Grout Inspection by Date �9anteca 823-7104 Final Inspection by Date 7BY ❑ Tracy 835-6385Applicant - Return all copies o vironmental Health Permit/Services 160Ave., P.O. Box 2009, Stk., CA95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVDATE PERMIT NO. INFO a 17-FS �-1 -i'1 C{ o EH 13-24 REV. 10/82 C)�J10/82 500 14-26 �<�ES i