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' Nv.sc,9>;e FAQ cis , 4 N0 (' (AS/M5!( APPLICATION FOR PERIf,iT SAN 70AQLiN LOCAL HEALTH DISTRICTHAZELTO 1 �U%o1601 E. lephone AUE., STOCKTON, CA pERh1IT NO.Telephone (209) 466-6781' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED /af� DATE ISSUED (Complein Triplitat ), _(,6l B E_1_e0,1 �L �f) 047— rv76 ?PPI�ication` is hereby made to the San Joaquin Local Hea th 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 Re uIations of. t San Joaauin Local Health District. Job Address ;� ` € Subdivision Name P � Owner's Name „f Address U one Contractor's Name License No. :r Phone r TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMFNT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR LJ OTHER U DISTANCE.-TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD• PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA I Industrial CONSTRUCTION SPECIFICATIONS U Open Bottom Manteca Dia, of Well Excavation Domestic/Private �. �--� (� Gravel Pack Tracy Dia, of Well Casing 14 Public CJ Other Delta LJ g Rpprox. Irri ation Eastern Type of Casing � ❑ Cathodic Protection Depth Specifications ❑Geophysical ; Depth of Grout Seal Other t Type of Grout n Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. so State Work Done Well Destruction U Well Diameter fL/ Sealing Material (top 501) �, 1 Depth J� Filler Material (Below 50') } � I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is 4 1 Installation will serve: Residence _ Commercial _ Other available within 200 feet.) 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 4. SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line ' DESTRUCTION ❑ LEACHING LINE U No. & Length of lines Total length/size y FILTER BED Distance to nearest: Well Foundation Property Line + a SEEPAGE PITS Cj Depth size Number SUMPS El Distance to nearest: Well Foundation Property Line' DISPOSAL PONDS �r 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 agch ent's signature certifies the following: "I certify that in the performance of the work for which this permit is iuedsha not employ any person in sumanner as to become subject to workman§compensation laws of California." Contractor'ssshiri g ors -contracting signature certifies the following: "I certify that in the performance of the work for which this permit is i sued, 11 a plo sons subject to workman's compensa n laws of California." The applicant t 11 f r red inspections. Complete drawing 9,K36erse side. L� Signed X Title:PRRTMENT USE LY f Date: f N Application Accepted by �/✓ Area — Stk 466-67 1 Additional Comment r. ❑\Lodi 369-3621 Pit or Grout Lnspection y Date � Manteca 823-7104 , Final Inspection Date � ❑ Tracy 835-6385 Applicant - Return all o 'es to: E ronm tal Health Permit/Services 1601 E. Hazelton 0e., P.D. Box 2D09, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED ;RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV, 10/82 10/82 500 14-26 t . A