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r � R s APPLICATION FOR PERMIT Z+ (' SAN 30AQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTOTelephone AVE-, STOCKTO66-6781 CA PERMIT N0. 13:1�3 2-- Telephone (209) 466-6781 ' PERMIT EXPIRES 3 YEAR FROM DATE ISSUED 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 No. 549 for sewage or No. I862 for well/pump and the Rule_ 4 eo n, )f the San Joaquin Local Health District, Job Addres s Subdivision Name Owner's Name m-' Address "' T �� Phone Contractor's Name License No. ' Phone Vic."k-2 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION E] '� n _ PUMP_[NSTALLATION �_ SYSTEM_REPAIR OTHER- D f DISTANCEITO NEAREST: SEPTIC TANK T SEWER LINES � pI5P05AL FLO, v" { T" �FpAOP'LINE N E ! FOUNDATION ¢ AG.RICULTURE WELL OTHER,WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION ,SpECIFICATIONS LJ Industrial _ I U Open Bottom i Manteca ❑ Dia. of Well•Excavation I V" ❑ Domestic/Private ❑Gravel Pack ❑ Tracy xDia,: of Well Casing i ❑ Publ i Other ❑] Delta t Irri ation Type of Casing w'� V 9 Approx. W❑ Eastern ❑ Cathodic Protection Depth '. Specifications a' t Geophysical : Depth of Grout Seal ❑Other; Type of Grout Surface Seal Installed by Type ❑ yP of Pum p Repair Work Done H.P. s �; - State Work Done r i, Well Destructio`❑ Well Diameter 1', '', Seal inq_Material `(top 50') !' f Depth 'xil.her'Ma'ferial'(Be.lowi5O') ! r — -� ti. TYPEi0 I5EPTIC-WORK. NEW°INSTALCR ION RF?ikI /1DDNibN E-j'57(.No'sept-ic-tank-or-seepage;pi-t-_Per-mi.tted i-fipubl.i-c�sewer.._i.sw 4 _ _w .:. i i available within 200 feet.) Instal>l,ation will serve:` Rest;dence L _Commircai,--t Dther� " � � rpf Number,of`l iving units,- _F Number-o-f;b_eft.0oms Lott.size Character fRsoil to d=rd1'pth of 3 feet: De 6 F '� Water table depth!. \SEPTIC TANK Type/Mfg s Ga,pacity -_ No. Compartments PKG. TREATMENT PLT. Q Type/Mfg Cap city No. of Disposal SEWAGE SYSTEM u Distance,to nearest: Well Foundation DESTRUCTION ❑`l Property, Line LEACHING L-INE No' Lengfh of lines -3 "� FT ` otal length/sized FILTER BED ❑ `lajrstance to nearest: Well Foundation Property Line s SEEPAGE PITS [j Dept ~Size Number f SUMPS �� Distancerfto nearest: Well € Foundation Property Line I DISPOSAL PONDS C�„ (; i y' k I hereby certify that I ha e. prepared this afpalication and that the workiwill be doneinaccordance with SanjJoaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I Home owner or licensed agent's signature certifies the followiing: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in sucA.manner", as to become subject to workman compensation'laws of California." Contractor's hiring or sub-contracting signature certifiesthe 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." i The applicant must cal forll required inspections. Complete drawing on reverse side. Signed X , Title: 4 , Date: F EP ENT USE ONL4Y ' 1 Application Accepted by RreaD 7 Stk 466-6781 Additional Comments: Q Lod; 369-3621 _Pit or Grout Inspection by t 4 Date ., L] Manteca 823-7104 Final Inspection by Date +, 3 ❑ Tracy, 835-6385 i Applicant - Return all copies to: Environ Health Permit/Services 1601, E. Hazelton Ave., P.O, Box 2009# Stk., CA 95201 .� FEENFO_ BASE AMOUNT DUE AMOUNT REMITTED , RECEIVEb BY DATE PERMIT NO. EH 13-24 REV. 10/82 14-26 10/82"600 I i