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a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t7 ,� 1601 E. HAZELTON AVE., STOCKT ON, CA �� pERMIT NO. I_Z--\-g 7 Telephone (209) 466-6781 DATE ISSUED A1�� PERMIT EXPIRES,1 YEAR FROM DATE ISSUED �i (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. 1862 for well/pump and the Rules and Regula//tg�ns of the aSaan Joaquin Local Health District. Job Addresslo 9,N-V! `> (� Subdivision Name Owner's game Z-1- /�j rdettfL/Address Phone 4�&;X 75k-3 Contractor's NameLicense No. Phone c�a TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT [] DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER 0 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 1� Industrial U Open Bottom Manteca Dia. of Well Excavation Domestic/Private Gravel Pack Tracy Dia. of Well Casing 17 Public F-1 Other ❑ Delta Type of Casing U Irrigation Approx. Eastern Specifications Cathodic Protection Depth (� Depth of Grout Seal Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done EJ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 501) O Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) 1p Installation will serve: Residence X 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 &Eapacity 1�1�� No. Compartments e G PKG. TREATMENT PLT, Type/Mfg Capacity Method of Disposal Distance to nearest: Well J(/t FoundationProperty Line /b r + LEACHING LINE No. & Length of lines Total length/size _ �Zo se o�� FILTER BED Distance to nearest: Well Foundation 0;L& Property Line /S V SEEPAGE PITS Depth Size ' ' 3"" Number / +{ yI r �i1 SUMPS Distance to nearest: Well Foundation Property Line Q ` DISPOSAL PONDS Cj 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 rulesand regulations of the San Joaquin Local Health District. qw 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 sh�aeD�ions, ploy persons subject to workman's compensation laws of California." The ap ant st call Complete dra ng on reverse side. Signed X Title: �� _W„ - -- Date: Z a Appli tion Accepted byj MEY Area Stk 466-6781 Additional Comments: drib ;� . - . iC= _ i[[[-fff eov�A/ Lodi 369-3621 N Pit or Grout Inspection by - Date / � �� Manteca 823-7104 Final Inspection by Date IL/S/ SCS- ❑ Tracy 835-6385 o- s Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO ] S oo �t=fib-g Z� EH 13-24 REV. 10/82 10/B2 500 14-26 �r