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APPLiCATICN FOR.PEnfa_T e3, SAN JOA L;!; LOCA'- HEALTH tiDiSTRIC v 1601 E. HAZELTON AVE., ST UCKTO k �� PERMIT NO.7R�I Telephone (209) 465-578 v� �,* C� DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE 15 s � (Complete in Triplicate) (n3*'�.r Application is hereby made to-the San Joaquin Local Health District for a permit tort 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 wel'd/pump and the Rules and Reegpuulat' of the San Ooaauinn Local Health District. 1i Job Address / 7)O /. 8 Ny *v Subdivision Name Owner's Name _r, d H'j `�. Address Z>4 TN-e— Phone Contractor's Name .11a, cense No. 121 -711r1610 Phone 93�� -� TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �� ( �} PUMP INSTALLATION ❑- SYSTEM REPAIR OTHER; ❑ II �/- DISTANCE TO NEAREST: SEPT.jC.TANK iz''•..!3! SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE W,ELL,,,____.. OTHER-WELL _ PITS/SUMPS - -... _.INTEND.ED...USE-----___.�.TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS "•'' 1J Industrial U Open Bottom ❑ Manteca Dia, of Well Excavation -.:,- Domestic/Private - ❑ Gravel Pack ❑Tracy Oia. of Well Casing. ,, ❑ Public ❑Other ❑ Delta Type of Casing- `y I IrrigationApprox•. Eastern !� 1. ;,, 1 ` Specifications ❑ Cathodic Pr-oiectiorl '1 . ` Depth �': �. 5 Dept1l`of Grout Seal 1! ❑GeophysicalI' �fk`Type of Grout U Other Surface Seal Installed byy/3�i Repair Work Dane Type of Pump H.Py - 'r State Work Done. 'RpV!m, e Well Destruction ❑ Well Diameter 4 Sealing Material (top 50'x) _. .. Depth '-Filler Material Below 50 J }, TYPE OF SEPTIC WORK: NEW INSTALLATION..❑I. REPAIR/ADDITION ED (No septic tank or, seepage pit permitted if public sewer is D available within 200 feet,) 'I Installation will serve: Residence _ Commercial. Other" I Number of living units'. Number of bedrooms ] , Lot size`. Character of soil -to,a"depth of 3 feet: '' Water table depth li 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 i "BEACHING LINE ❑ No. & Length of lines Total length%size FILTER BED I❑ Distance to nearest: Well Foundation Property Line i+x SEEPAGE PITS 1. — Depth ;-'N t '; _`)..-'Size ' l• _-. . Number 1 1 SUMPS ❑- :Distance totnearest:'�Well Faundatior Property Line DISPOSAL PONDS ❑I 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. 1_� Home owner or licensed agent's signature certifies the following: "I certify that in the performance of-the work-flfr•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 s 11 ploy persons subject to workman's compensation laws of California." The applica ust all r equired inspections. Complete dr ling on reverse side. Title: Date: /�3-� Signed X FOR QE M6N 1S E. ONLY~ ) �, Application Accepted by rear' ❑ Stk 466-678I M Additional Comments: L 369-3621 Pit or Grout Inspectiv Date ❑ Manteca 823-7104 h1 Final Inspection by Date ❑ Tracy 835-6385 fl Applicant - Return all copies to: Environmerta ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 91'201 I rEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATES PERMIT N0. ly. e2 _V�' I ifi EH 13-24 REV. 10/82 10/82 500 1 14-26 .F